the presentation of fetus

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

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

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

Head down, face down

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

Head down, face up

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

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

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

Frank breech

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

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

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

Complete and incomplete breech

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Fetal presentation and position

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

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

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

Medical illustrations by Jonathan Dimes

Head down, facing down (anterior position)

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

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

Head down, facing up (posterior position)

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

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

Frank breech

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

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

Complete breech

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

Incomplete breech

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

Single footling breech

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

Double footling breech

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

Transverse lie

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

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

Oblique lie

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

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

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What to know if your baby is breech

What's a sunny-side up baby?

What happens to your baby right after birth

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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 .

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

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

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

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

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Presentation and position of baby through pregnancy and at birth

9-minute read

If you are concerned about your baby’s movements, contact your doctor or midwife for advice immediately.

• If you baby is in a breech presentation, your doctor may recommend trying a technique called an external cephalic version to try and move your baby while they are still in the uterus for an easier birth.

What does presentation and position mean?

Presentation refers to the part of your baby’s body that is facing downwards in the direction of the birth canal.

Position refers to where your baby’s occiput (the bottom part of the back of their head) is in relation to your body.

If your baby is in a breech presentation , then position refers to where your baby’s sacrum (lower back) is in relation to your body.

People — including medical professionals — sometimes use these terms incorrectly. Sometimes when speaking about babies in breech presentation, the word ‘position’ will be used to refer to their presentation. For example, you may read information or hear people say ‘breech position’ instead of ‘breech presentation’.

What are the different types of presentation my baby could be in during pregnancy and birth?

Most babies present headfirst, also known as cephalic presentation. Most babies that are headfirst will be vertex presentation. This means that the crown of their head sits at the opening of your birth canal.

In rare cases, your baby can be headfirst but in face or brow presentation, which may not be suitable for vaginal birth.

If your baby is in a breech presentation, their feet or bottom will be closest to your birth canal. The 3 most common types of breech presentation are:

• frank or extended breech — where your baby’s legs are straight up in front of their body, with their feet up near their face
• complete or flexed breech — where your baby is in a sitting position with their legs crossed in front of their body and their feet near their bottom
• footling breech — where one or both of your baby’s feet are hanging below their bottom, so the foot or feet are coming first

Read more on breech presentation .

What are the different positions my baby could be in during pregnancy and birth?

If your baby is headfirst, the 3 main types of presentation are:

• anterior – when the back of your baby’s head is at the front of your belly
• lateral – when the back of your baby’s head is facing your side
• posterior – when the back of your baby’s head is towards your back

How will I know what presentation and position my baby is in?

Your doctor or midwife can usually work out your baby’s presentation by feeling your abdomen. They may also double check it with a portable ultrasound. Your baby’s presentation is usually checked around 36 weeks .

Your doctor or midwife will also confirm your baby’s head position in labour by examining your belly and using an ultrasound , and they may also do a vaginal examination . During the vaginal examination they are feeling for certain ridges on your baby’s head called sutures and fontanelles that help them work out which way your baby is positioned.

What is the ideal presentation and position for baby to be in for a vaginal birth?

For a vaginal birth, your baby will ideally be headfirst with the back of their head at the front of your belly, also known as being in the anterior position. This position is best for labour and birth since it means that the smallest part of your baby’s head goes down the birth canal first.

When does a baby usually get in the ideal presentation and position for birth?

Your baby will usually be in a headfirst position by 37 weeks of pregnancy. Around 3 in every 100 babies will be in breech presentation after 37 weeks.

Your baby’s position can change with your contractions during labour as they move down the birth canal, so their exact position can change during labour.

What are my options if baby isn't in the ideal presentation or position for a vaginal birth?

If your baby is in a breech presentation, your doctor may recommend a technique called an external cephalic version (ECV) to try and move your baby while they are still in the uterus . An ECV involves your doctor using their hands to apply pressure on your belly and help turn your baby to a headfirst position. It has a 1 in 2 chance of success and is a safe option in most pregnancies.

There is no evidence to show that alternative therapies, such as exercises, acupuncture or chiropractic treatments, help your baby change from a breech presentation to headfirst.

If your baby remains breech, your doctor may discuss having a breech vaginal birth. Not all doctors and hospitals offer this option. They may also suggest you birth your baby with a planned caesarean section .

If your baby’s presentation is headfirst but the position of your baby’s head is not ideal for labour, it can lead to a longer labour, and potential complications . The position of your baby’s head will often change as your labour progresses. If it doesn’t, sometimes you can still give birth without assistance, or you may need your doctor to help turn your baby’s head or help your birth with a vacuum or forceps .

Any procedure or decision for a type of birth will only go ahead with your consent . You will be able to discuss all the options with your doctor, and based on your preferences for yourself and your baby’s safety, make a decision together .

Resources and support

The Royal Australian and New Zealand College of Obstetrics and Gynaecology has a factsheet about the options available to you if your baby is in a breech presentation at the end of your pregnancy .

Mercy Perinatal has information on external cephalic version (ECV) safety and benefits if your baby is in a breech presentation at the end of your pregnancy.

The Women’s Hospital has information about the different presentations and positions your baby could be in, and how it can affect your birthing experience.

Speak to a maternal child health nurse

Call Pregnancy, Birth and Baby to speak to a maternal child health nurse on 1800 882 436 or video call . Available 7am to midnight (AET), 7 days a week.

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Last reviewed: October 2023

Related pages

External cephalic version (ecv), malpresentation, breech pregnancy, search our site for.

• Foetal Version
• Breech Presentation

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Breech presentation and turning the baby

In preparation for a safe birth, your health team will need to turn your baby if it is in a bottom first ‘breech’ position.

Read more on WA Health website

Breech Presentation at the End of your Pregnancy

Breech presentation occurs when your baby is lying bottom first or feet first in the uterus (womb) rather than the usual head first position. In early pregnancy, a breech position is very common.

Read more on RANZCOG - Royal Australian and New Zealand College of Obstetricians and Gynaecologists website

External Cephalic Version for Breech Presentation - Pregnancy and the first five years

This information brochure provides information about an External Cephalic Version (ECV) for breech presentation

Read more on NSW Health website

When a baby is positioned bottom-down late in pregnancy, this is called the breech position. Find out about 3 main types and safe birthing options.

Read more on Pregnancy, Birth & Baby website

Malpresentation is when your baby is in an unusual position as the birth approaches. Sometimes it’s possible to move the baby, but a caesarean maybe safer.

Labour complications

Even if you’re healthy and well prepared for childbirth, there’s always a chance of unexpected problems. Learn more about labour complications.

ECV is a procedure to try to move your baby from a breech position to a head-down position. This is performed by a trained doctor.

Having a baby

The articles in this section relate to having a baby – what to consider before becoming pregnant, pregnancy and birth, and after your baby is born.

Anatomy of pregnancy and birth - pelvis

Your pelvis helps to carry your growing baby and is tailored for vaginal births. Learn more about the structure and function of the female pelvis.

Birth injury (to the baby)

Giving birth in Australia is very safe, but sometimes during birth, the baby suffers an injury. Learn about birth injury causes, types and treatments.

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Fetal Positions for Labor and Birth

Knowing your baby's position can you help ease pain and speed up labor

In the last weeks of pregnancy , determining your baby's position can help you manage pain and discomfort. Knowing your baby's position during early labor can help you adjust your own position during labor and possibly even speed up the process.

Right or Left Occiput Anterior

Illustration by JR Bee, Verywell 

Looking at where the baby's head is in the birth canal helps determine the fetal position.The front of a baby's head is referred to as the anterior portion and the back is the posterior portion. There are two different positions called occiput anterior (OA) positions that may occur.

The left occiput anterior (LOA) position is the most common in labor. In this position, the baby's head is slightly off-center in the pelvis with the back of the head toward the mother's left thigh.

The right occiput anterior (ROA) presentation is also common in labor. In this position, the back of the baby is slightly off-center in the pelvis with the back of the head toward the mother's right thigh.

In general, OA positions do not lead to problems or additional pain during labor or birth.  

Right or Left Occiput Transverse

Illustration by JR Bee, Verywell  

When facing out toward the mother's right thigh, the baby is said to be left occiput transverse (LOT). This position is halfway between a posterior and anterior position. If the baby was previously in a posterior position (in either direction), the LOT position indicates positive movement toward an anterior position.

When the baby is facing outward toward the mother's left thigh, the baby is said to be right occiput transverse (ROT). Like the previous presentation, ROT is halfway between a posterior and anterior position. If the baby was previously in a posterior position, ROT is a sign the baby is making a positive move toward an anterior position.

When a baby is in the left occiput transverse position (LOT) or right occiput transverse (ROT) position during labor, it may lead to more pain and a slower progression.

Tips to Reduce Discomfort

There are several labor positions a mother can try to alleviate pain and encourage the baby to continue rotating toward an anterior position, including:

• Pelvic tilts
• Standing and swaying

A doula , labor nurse, midwife , or doctor may have other suggestions for positions.

Right or Left Occiput Posterior

When facing forward, the baby is in the occiput posterior position. If the baby is facing forward and slightly to the left (looking toward the mother's right thigh) it is in the left occiput posterior (LOP) position. This presentation can lead to more back pain (sometimes referred to as " back labor ") and slow progression of labor.

In the right occiput posterior position (ROP), the baby is facing forward and slightly to the right (looking toward the mother's left thigh). This presentation may slow labor and cause more pain.

To help prevent or decrease pain during labor and encourage the baby to move into a better position for delivery, mothers can try a variety of positions, including:

• Hands and knees
• Pelvic rocking

Mothers may try other comfort measures, including:

• Bathtub or shower (water)
• Counter pressure
• Movement (swaying, dancing, sitting on a birth ball )
• Rice socks (heat packs)

How a Doctor Determines Baby's Position

Leopold's maneuvers are a series of hands-on examinations your doctor or midwife will use to help determine your baby's position. During the third trimester , the assessment will be done at most of your prenatal visits.   Knowing the baby's position before labor begins can help you prepare for labor and delivery.

Once labor begins, a nurse, doctor, or midwife will be able to get a more accurate sense of your baby's position by performing a vaginal exam. When your cervix is dilated enough, the practitioner will insert their fingers into the vagina and feel for the suture lines of the baby's skull as it moves down in the birth canal.   It's important to ensure the baby is head down and moving in the right direction.

Labor and delivery may be more complicated if the baby is not in a head-down position, such as in the case of a breech presentation.

How You Can Determine Baby's Position

While exams by health practitioners are an important part of your care, from the prenatal period through labor and delivery, often the best person to assess a baby's position in the pelvis is you. Mothers should pay close attention to how the baby moves and where different movements are felt.

A technique called belly mapping can help mothers ask questions of themselves to assess their baby's movement and get a sense of the position they are in as labor approaches.

For example, the position of your baby's legs can be determined by asking questions about the location and strength of the kicking you feel. The spots where you feel the strongest kicks are most likely where your baby's feet are.

Other landmarks you can feel for include a large, flat plane, which is most likely your baby's back. Sometimes you can feel the baby arching his or her back.

At the top or bottom of the flat plane, you may feel either a hard, round shape (most likely your baby's head) or a soft curve (most likely to be your baby's bottom).

Guittier M, Othenin-Girard V, de Gasquet B, Irion O, Boulvain M. Maternal positioning to correct occiput posterior fetal position during the first stage of labour: a randomised controlled trial .  BJOG: An International Journal of Obstetrics & Gynaecology . 2016;123(13):2199-2207. doi:10.1111/1471-0528.13855

Gizzo S, Di Gangi S, Noventa M, Bacile V, Zambon A, Nardelli G. Women’s Choice of Positions during Labour: Return to the Past or a Modern Way to Give Birth? A Cohort Study in Italy .  Biomed Res Int . 2014;2014:1-7. doi:10.1155/2014/638093

Ahmad A, Webb S, Early B, Sitch A, Khan K, MacArthur C. Association between fetal position at onset of labor and mode of delivery: a prospective cohort study .  Ultrasound in Obstetrics & Gynecology . 2014;43(2):176-182. doi:10.1002/uog.13189

Nishikawa M, Sakakibara H. Effect of nursing intervention program using abdominal palpation of Leopold’s maneuvers on maternal-fetal attachment .  Reprod Health . 2013;10(1). doi:10.1186/1742-4755-10-12

Choi S, Park Y, Lee D, Ko H, Park I, Shin J. Sonographic assessment of fetal occiput position during labor for the prediction of labor dystocia and perinatal outcomes .  The Journal of Maternal-Fetal & Neonatal Medicine . 2016;29(24):3988-3992. doi:10.3109/14767058.2016.1152250

Bamberg C, Deprest J, Sindhwani N et al. Evaluating fetal head dimension changes during labor using open magnetic resonance imaging .  J Perinat Med . 2017;45(3). doi:10.1515/jpm-2016-0005

Gabbe S, Niebyl J, Simpson J et al.  Obstetrics . Philadelphia, Pa.: Elsevier; 2012.

By Robin Elise Weiss, PhD, MPH Robin Elise Weiss, PhD, MPH is a professor, author, childbirth and postpartum educator, certified doula, and lactation counselor.

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Your baby in the birth canal

During labor and delivery, your baby must pass through your pelvic bones to reach the vaginal opening. The goal is to find the easiest way out. Certain body positions give the baby a smaller shape, which makes it easier for your baby to get through this tight passage.

The best position for the baby to pass through the pelvis is with the head down and the body facing toward the mother's back. This position is called occiput anterior.

Information

Certain terms are used to describe your baby's position and movement through the birth canal.

FETAL STATION

Fetal station refers to where the presenting part is in your pelvis.

• The presenting part. The presenting part is the part of the baby that leads the way through the birth canal. Most often, it is the baby's head, but it can be a shoulder, the buttocks, or the feet.
• Ischial spines. These are bone points on the mother's pelvis. Normally the ischial spines are the narrowest part of the pelvis.
• 0 station. This is when the baby's head is even with the ischial spines. The baby is said to be "engaged" when the largest part of the head has entered the pelvis.
• If the presenting part lies above the ischial spines, the station is reported as a negative number from -1 to -5.

In first-time moms, the baby's head may engage by 36 weeks into the pregnancy. However, engagement may happen later in the pregnancy, or even during labor.

This refers to how the baby's spine lines up with the mother's spine. Your baby's spine is between their head and tailbone.

Your baby will most often settle into a position in the pelvis before labor begins.

• If your baby's spine runs in the same direction (parallel) as your spine, the baby is said to be in a longitudinal lie. Nearly all babies are in a longitudinal lie.
• If the baby is sideways (at a 90-degree angle to your spine), the baby is said to be in a transverse lie.

FETAL ATTITUDE

The fetal attitude describes the position of the parts of your baby's body.

The normal fetal attitude is commonly called the fetal position.

• The head is tucked down to the chest.
• The arms and legs are drawn in towards the center of the chest.

Abnormal fetal attitudes include a head that is tilted back, so the brow or the face presents first. Other body parts may be positioned behind the back. When this happens, the presenting part will be larger as it passes through the pelvis. This makes delivery more difficult.

DELIVERY PRESENTATION

Delivery presentation describes the way the baby is positioned to come down the birth canal for delivery.

The best position for your baby inside your uterus at the time of delivery is head down. This is called cephalic presentation.

• This position makes it easier and safer for your baby to pass through the birth canal. Cephalic presentation occurs in about 97% of deliveries.
• There are different types of cephalic presentation, which depend on the position of the baby's limbs and head (fetal attitude).

If your baby is in any position other than head down, your doctor may recommend a cesarean delivery.

Breech presentation is when the baby's bottom is down. Breech presentation occurs about 3% of the time. There are a few types of breech:

• A complete breech is when the buttocks present first and both the hips and knees are flexed.
• A frank breech is when the hips are flexed so the legs are straight and completely drawn up toward the chest.
• Other breech positions occur when either the feet or knees present first.

The shoulder, arm, or trunk may present first if the fetus is in a transverse lie. This type of presentation occurs less than 1% of the time. Transverse lie is more common when you deliver before your due date, or have twins or triplets.

CARDINAL MOVEMENTS OF LABOR

As your baby passes through the birth canal, the baby's head will change positions. These changes are needed for your baby to fit and move through your pelvis. These movements of your baby's head are called cardinal movements of labor.

• This is when the widest part of your baby's head has entered the pelvis.
• Engagement tells your health care provider that your pelvis is large enough to allow the baby's head to move down (descend).
• This is when your baby's head moves down (descends) further through your pelvis.
• Most often, descent occurs during labor, either as the cervix dilates or after you begin pushing.
• During descent, the baby's head is flexed down so that the chin touches the chest.
• With the chin tucked, it is easier for the baby's head to pass through the pelvis.

Internal Rotation

• As your baby's head descends further, the head will most often rotate so the back of the head is just below your pubic bone. This helps the head fit the shape of your pelvis.
• Usually, the baby will be face down toward your spine.
• Sometimes, the baby will rotate so it faces up toward the pubic bone.
• As your baby's head rotates, extends, or flexes during labor, the body will stay in position with one shoulder down toward your spine and one shoulder up toward your belly.
• As your baby reaches the opening of the vagina, usually the back of the head is in contact with your pubic bone.
• At this point, the birth canal curves upward, and the baby's head must extend back. It rotates under and around the pubic bone.

External Rotation

• As the baby's head is delivered, it will rotate a quarter turn to be in line with the body.
• After the head is delivered, the top shoulder is delivered under the pubic bone.
• After the shoulder, the rest of the body is usually delivered without a problem.

Alternative Names

Shoulder presentation; Malpresentations; Breech birth; Cephalic presentation; Fetal lie; Fetal attitude; Fetal descent; Fetal station; Cardinal movements; Labor-birth canal; Delivery-birth canal

Barth WH. Malpresentations and malposition. In: Landon MB, Galan HL, Jauniaux ERM, et al, eds. Gabbe's Obstetrics: Normal and Problem Pregnancies . 8th ed. Philadelphia, PA: Elsevier; 2021:chap 17.

Kilpatrick SJ, Garrison E, Fairbrother E. Normal labor and delivery. In: Landon MB, Galan HL, Jauniaux ERM, et al, eds. Gabbe's Obstetrics: Normal and Problem Pregnancies . 8th ed. Philadelphia, PA: Elsevier; 2021:chap 11.

Review Date 11/10/2022

Updated by: John D. Jacobson, MD, Department of Obstetrics and Gynecology, Loma Linda University School of Medicine, Loma Linda, CA. Also reviewed by David C. Dugdale, MD, Medical Director, Brenda Conaway, Editorial Director, and the A.D.A.M. Editorial team.

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

, MD, Children's Hospital of Philadelphia

Variations in Fetal Position and Presentation

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

Position refers to whether the fetus is facing backward (occiput anterior) or forward (occiput posterior). The occiput is a bone at the back of the baby's head. Therefore, facing backward is called occiput anterior (facing the mother’s back and facing down when the mother lies on her back). Facing forward is called occiput posterior (facing toward the mother's pubic bone and facing up when the mother lies on her back).

Lie refers to the angle of the fetus in relation to the mother and the uterus. Up-and-down (with the baby's spine parallel to mother's spine, called longitudinal) is normal, but sometimes the lie is sideways (transverse) or at an angle (oblique).

For these aspects of fetal positioning, the combination that is the most common, safest, and easiest for the mother to deliver is the following:

Head first (called vertex or cephalic presentation)

Facing backward (occiput anterior position)

Spine parallel to mother's spine (longitudinal lie)

Neck bent forward with chin tucked

Arms folded across the chest

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

Variations in fetal presentation, position, or lie may occur when

The fetus is too large for the mother's pelvis (fetopelvic disproportion).

The fetus has a birth defect Overview of Birth Defects Birth defects, also called congenital anomalies, are physical abnormalities that occur before a baby is born. They are usually obvious within the first year of life. The cause of many birth... read more .

There is more than one fetus (multiple gestation).

Position and Presentation of the Fetus

Some variations in position and presentation that make delivery difficult occur frequently.

Occiput posterior position

In occiput posterior position (sometimes called sunny-side up), the fetus is head first (vertex presentation) but is facing forward (toward the mother's pubic bone—that is, facing up when the mother lies on her back). This is a very common position that is not abnormal, but it makes delivery more difficult than when the fetus is in the occiput anterior position (facing toward the mother's spine—that is facing down when the mother lies on her back).

Breech presentation

In breech presentation, the baby's buttocks or sometimes the feet are positioned to deliver first (before the head).

When delivered vaginally, babies that present buttocks first are more at risk of injury or even death than those that present head first.

The reason for the risks to babies in breech presentation is that the baby's hips and buttocks are not as wide as the head. Therefore, when the hips and buttocks pass through the cervix first, the passageway may not be wide enough for the head to pass through. In addition, when the head follows the buttocks, the neck may be bent slightly backwards. The neck being bent backward increases the width required for delivery as compared to when the head is angled forward with the chin tucked, which is the position that is easiest for delivery. Thus, the baby’s body may be delivered and then the head may get caught and not be able to pass through the birth canal. When the baby’s head is caught, this puts pressure on the umbilical cord in the birth canal, so that very little oxygen can reach the baby. Brain damage due to lack of oxygen is more common among breech babies than among those presenting head first.

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

Labor starts too soon (preterm labor).

Sometimes the doctor can turn the fetus to be head first before labor begins by doing a procedure that involves pressing on the pregnant woman’s abdomen and trying to turn the baby around. Trying to turn the baby is called an external cephalic version and is usually done at 37 or 38 weeks of pregnancy. Sometimes women are given a medication (such as terbutaline ) during the procedure to prevent contractions.

Other presentations

In face presentation, the baby's neck arches back so that the face presents first rather than the top of the head.

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

Usually, fetuses do not stay in a face or brow presentation. These presentations often change to a vertex (top of the head) presentation before or during labor. If they do not, a cesarean delivery is usually recommended.

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

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

StatPearls [Internet].

Stages of labor.

Julia Hutchison ; Heba Mahdy ; Justin Hutchison .

Affiliations

Last Update: January 30, 2023 .

• Continuing Education Activity

Labor is a process that subdivides into three stages. The first stage starts when labor begins and ends with full cervical dilation and effacement. The second stage commences with complete cervical dilation and ends with the delivery of the fetus. The third stage initiates after the fetus is delivered and ends when the placenta is delivered. This activity outlines the stages of labor and its relevance to the interprofessional team in managing women in labor.

• Summarize the three stages of labor.
• Describe potential complications that may arise during each stage of labor.
• Identify what therapies may be targeted at the different stages of labor to result in better patient outcomes.
• Review the importance of accurate communication between the interprofessional team members regarding the stages of labor, leading to improved patient outcomes.
• Introduction

Labor is the process through which a fetus and placenta are delivered from the uterus through the vagina. [1]  Human labor divides into three stages. The first stage is further divided into two phases. Successful labor involves three factors: maternal efforts and uterine contractions, fetal characteristics, and pelvic anatomy. [1] This triad is classically referred to as the passenger, power, and passage. [1]  Clinicians typically use multiple modalities to monitor labor. Serial cervical examinations are used to determine cervical dilation, effacement, and fetal position, also known as the station. Fetal heart monitoring is employed nearly continuously to assess fetal well-being throughout labor. Cardiotocography is used to monitor the frequency and adequacy of contractions. Medical professionals use the information they obtain from monitoring and cervical exams to determine the patient's stage of labor and monitor labor progression.

Initial Evaluation and Presentation of Labor

Women will often self-present to obstetrical triage with concern for the onset of labor. Common chief complaints include painful contractions, vaginal bleeding/bloody show, and fluid leakage from the vagina. It is up to the clinician to determine if the patient is in labor, defined as regular, clinically significant contractions with an objective change in cervical dilation and/or effacement. [1] When women first present to the labor and delivery unit, vital signs, including temperature, heart rate, oxygen saturation, respiratory rate, and blood pressure, should be obtained and reviewed for any abnormalities. The patient should be placed on continuous cardiotocographic monitoring to ensure fetal wellbeing. The patient's prenatal record, including obstetric history, surgical history, medical history, laboratory, and imaging data, should undergo review. Finally, a history of present illness, review of systems, and physical exam, including a sterile speculum exam, will need to take place.

During the sterile speculum exam, clinicians will look for signs of rupture of membranes such as amniotic fluid pooling in the posterior vaginal canal. If the clinician is unsure whether or not a rupture of membranes has occurred, additional testing such as pH testing, microscopic exam looking for ferning of the fluid, or laboratory testing of the fluid can be the next step. [2] Amniotic fluid has a pH of 7.0 to 7.5, which is more basic than normal vaginal pH. A sterile gloved exam should be done to determine the degree of cervical dilation and effacement. The measurement of cervical dilation is made by locating the external cervical os and spreading one's fingers in a ‘V’ shape, and estimating the distance in centimeters between the two fingers. Effacement is measured by estimating the percentage remaining of the length of the thinned cervix compared to the uneffaced cervix. During the cervical exam, confirmation of the presenting fetal part is also necessary. Bedside ultrasound can be employed to confirm the presentation and position of the fetal presenting part. Particular mention should be noted in the case of breech presentation due to its increased risks regarding fetal morbidity and mortality compared with the cephalic presenting fetus. 

Management of Normal Labor

Labor is a natural process, but it can suffer interruption by complicating factors, which at times necessitate clinical intervention. The management of low-risk labor is a delicate balance between allowing the natural process to proceed while limiting any potential complications. [3] During labor, cardiotocographic monitoring is often employed to monitor uterine contractions and fetal heart rate over time. Clinicians monitor fetal heart tracings to evaluate for any signs of fetal distress that would warrant intervention as well as the adequacy or inadequacy of contractions. Vital signs of the mother are taken at regular intervals and whenever concerns arise regarding a clinical status change. Laboratory testing often includes the hemoglobin, hematocrit, and platelet count and is sometimes repeated following delivery if significant blood loss occurs. Cervical exams are usually performed every 2 to 3 hours unless concerns arise and warrant more frequent exams. Frequent cervical exams are associated with a higher risk of infection, especially if a rupture of membranes has occurred. Women should be allowed to ambulated freely and change positions if desired. [3]  An intravenous catheter is typically inserted in case it is necessary to administer medications or fluids. Oral intake should not be withheld. If the patient remains without food or drink for a prolonged period of time, intravenous fluids should be considered to help replace losses but do not need to be used continuously on all laboring patients. [3] Analgesia is offered in the form of intravenous opioids, inhaled nitrous oxide, and neuraxial analgesia in those who are appropriate candidates. [4] Amniotomy is considered on an as-needed basis for fetal scalp monitoring or labor augmentation, but its routine use should be discouraged. [3] Oxytocin may be initiated to augment contractions found to be inadequate.

First Stage of Labor

The first stage of labor begins when labor starts and ends with full cervical dilation to 10 centimeters. [1] Labor often begins spontaneously or may be induced medically for a variety of maternal or fetal indications. [5] Methods of inducing labor include cervical ripening with prostaglandins, membrane stripping, amniotomy, and intravenous oxytocin. [5] Although precisely determining when labor starts may be inexact, labor is generally defined as beginning when contractions become strong and regularly spaced at approximately 3 to 5 minutes apart. [1] Women may experience painful contractions throughout pregnancy that do not lead to cervical dilation or effacement, referred to as false labor. Thus, defining the onset of labor often relies on retrospective or subjective data. Friedman et al. were some of the first to study labor progress and defined the beginning of labor as starting when women felt significant and regular contractions. [6] He graphed cervical dilation over time and determined that normal labor has a sigmoidal shape. Based on the analysis from his labor graphs, he proposed that labor has three divisions. First, a preparatory stage marked by slow cervical dilation, with large biochemical and structural changes. This is also known as the latent phase of the first stage of labor. Second, a much shorter and rapid dilational phase is also known as the active phase of the first stage of labor. Third, a pelvic division phase, which takes place during the second stage of labor. [1]

The first stage of labor is further subdivides into two phases, defined by the degree of cervical dilation. The latent phase is commonly defined as the 0 to 6 cm, while the active phase commences from 6 cm to full cervical dilation. The presenting fetal part also begins the process of engagement into the pelvis during the first stage. Throughout the first stage of labor, serial cervical exams are done to determine the position of the fetus, cervical dilation, and cervical effacement. Cervical effacement refers to the cervical length in the anterior-posterior plane. When the cervix is completely thinned out, and no length is left, this is referred to as 100 percent effacement. [1]  The station of the fetus is defined relative to its position in the maternal pelvis.  When the bony fetal presenting part is aligned with the maternal ischial spine, the fetus is 0 station. Proximal to the ischial spines are stations -1 centimeter to -5 centimeters, and distal to the ischial spines is +1 to +5 station. [1] The first stage of labor contains a latent phase and an active phase. During the latent phase, the cervix dilates slowly to approximately 6 centimeters. The latent phase is generally considerably longer and less predictable with regard to the rate of cervical change than is observed in the active phase. A normal latent phase can last up to 20 hours and 14 hours in nulliparous and multiparous women, respectively, without being considered prolonged. [1] Sedation can increase the duration of the latent phase of labor. [7] The cervix changes more rapidly and predictably in the active phase until it reaches 10 centimeters and cervical dilation and effacement are complete. Active labor with more rapid cervical dilation generally starts around 6 centimeters of dilation. During the active phase, the cervix typically dilates at a rate of 1.2 to 1.5 centimeters per hour. Multiparas, or women with a history of prior vaginal delivery, tend to demonstrate more rapid cervical dilation. [1] The absence of cervical change for greater than 4 hours in the presence of adequate contractions or six hours with inadequate contractions is considered the arrest of labor and may warrant clinical intervention. [7]  

Second Stage of Labor

The second stage of labor commences with complete cervical dilation to 10 centimeters and ends with the delivery of the neonate. This was also defined as the pelvic division phase by Friedman. After cervical dilation is complete, the fetus descends into the vaginal canal with or without maternal pushing efforts. The fetus passes through the birth canal via 7 movements known as the cardinal movements.  These include engagement, descent, flexion, internal rotation, extension, external rotation, and expulsion. [1]  In women who have delivered vaginally previously, whose bodies have acclimated to delivering a fetus, the second stage may only require a brief trial, whereas a longer duration may be required for a nulliparous female. In parturients without neuraxial anesthesia, the second stage of labor typically lasts less than three hours in nulliparous women and less than two hours in multiparous women. In women who receive neuraxial anesthesia, the second stage of labor typically lasts less than four hours in nulliparous women and less than three hours in multiparous women. [1]  If the second stage of labor lasts longer than these parameters, then the second stage is considered prolonged. Several elements may influence the duration of the second stage of labor, including fetal factors such as fetal size and position, or maternal factors such as pelvis shape, the magnitude of expulsive efforts, comorbidities such as hypertension or diabetes, age, and history of previous deliveries. [8]  

Third Stage of Labor

The third stage of labor commences when the fetus is delivered and concludes with the delivery of the placenta. Separation of the placenta from the uterine interface is hallmarked by three cardinal signs, including a gush of blood at the vagina, lengthening of the umbilical cord, and a globular shaped uterine fundus on palpation. [1]  Spontaneous expulsion of the placenta typically takes between 5 to 30 minutes. [1] A delivery time of greater than 30 minutes is associated with a higher risk of postpartum hemorrhage and may be an indication for manual removal or other intervention. [1]  Management of the third stage of labor involves placing traction on the umbilical cord with simultaneous fundal pressure to effect faster placental delivery. 

The function of the stages of labor is to create a universal definition that medical professionals can use to communicate with each other about labor. The stages of labor can be used to help determine where the patient is on the labor spectrum. Clarifying the stages of labor has helped create guidelines, which define normal and abnormal trends in labor. Clinical management also gears toward the various stages of labor. 

• Issues of Concern

Complications may arise during any of the stages of labor to result in abnormal labor. During the first stage, women may experience the arrest of parturition, necessitating cesarian delivery, which may carry greater maternal or fetal risk. Second stage complications include a variety of complications related to the trauma of the delivery process to either the fetus or the mother. The fetus can suffer acidemia, shoulder dystocia, bony fractures, nerve palsies, scalp hematomas, and anoxic brain injuries. Similarly, the mother can develop a host of traumatic complications ranging from uterine rupture, vaginal laceration, cervical laceration, uterine hemorrhage, amniotic fluid embolism, and death. The third stage of labor may encounter complications from hemorrhage, cord avulsion, retained placenta, or incomplete removal of the placenta. [5]

• Clinical Significance

Defining the stages of labor with a specific beginning and end has allowed clinicians to study labor trends and to create labor curves. For example, in the 1950s, Dr. Friedman created a graphical representation of the rate of normal labor during latent and active labor using observed clinical data. [9] These, in turn, can be used to determine if a woman is progressing through labor as expected and helping to identify abnormal labor. Friedman observed that labor typically has a sigmoidal shape when measured by cervical dilation over time. During the active phase of labor, cervical dilation occurs at a rate of 1 centimeter or more per hour.  If dilation occurs much slower, the patient may be at risk for abnormal labor or arrest of labor. [10]  

If a woman is found not progressing through the first stage of labor as expected, this could lead to the diagnosis of the arrest of dilation or descent, which could result in cesarean delivery. The findings of Dr. Friedman have recently been challenged, and the current consensus is the normal latent phase of labor lasts longer than was previously observed. [8]  The criteria for the stages of labor create a universal language that allows healthcare professionals to communicate with one another about patient care accurately. Also, specific interventions are tailored to particular stages of labor to try to create better patient outcomes. For example, active management in the third stage of labor is carried out by placing immediate traction on the umbilical cord and administering intravenous oxytocin, which correlates with a lower risk of postpartum hemorrhage. [11] Clinicians will continue to use the stages of labor to guide labor management and study labor patterns to improve patient care.

• Enhancing Healthcare Team Outcomes

The stages of labor describe a complex physiologic process that starts when labor beings and ends with the delivery of the fetus and placenta. Labor is usually monitored clinically with multiple modalities by an interprofessional team. The process of labor can proceed as typically expected with certain cardinal events and time parameters or can encounter complications and delays, which may require identification and medical intervention.

The role of the interprofessional team in monitoring and caring for women during labor is critically important in keeping women safe and improving outcomes during the labor process.

A wide variety of medical professionals such as nurses, midwives, pharmacists, family physicians, anesthesiologists, and obstetrician/gynecologists may be involved in a woman’s labor process. Close communication is needed between these professionals to create an atmosphere of safety and patient-centered care. Midwives often manage labor and delivery and work closely with physicians when complications arise, requiring physician intervention, such as Caesarian section or operative delivery. Pharmacists ensure that patients receive the proper analgesics, tocolytics, and other medications that may be needed during or following labor. Anesthesiologists and nurse anesthetists administer epidurals for analgesia and are available for general endotracheal anesthesia when necessary. Nurses monitor the patient’s vital signs, contractions, cervical exams, pain scores, administer medications, recognize complications, and update the physician or midwife responsible for the patient. Each labor is unique, but an interprofessional approach prenatally and during labor can be used to improve patient outcomes and provide patient-centered care, as each provider class works collaboratively to ensure communication lines remain open between different disciplines on the health care team [Level 5]

A Canadian retrospective cohort study of 1238 women found that an interprofessional team approach to obstetrical care was shown to provide better patient outcomes by decreasing the rate of cesarian sections and length of hospital stays for women. [12]  [Level 4]

• Nursing, Allied Health, and Interprofessional Team Interventions

Nurses are intimately involved in monitoring and caring for laboring women. Nurses administer and titrate medications during labor, such as oxytocin. Nurses monitor the vital signs, pain scores, and labor progression of women and fetuses closely and are responsible for recognizing and then notifying physicians and midwives when abnormalities arise.

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Disclosure: Julia Hutchison declares no relevant financial relationships with ineligible companies.

Disclosure: Heba Mahdy declares no relevant financial relationships with ineligible companies.

Disclosure: Justin Hutchison 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 Hutchison J, Mahdy H, Hutchison J. Stages of Labor. [Updated 2023 Jan 30]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-.

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

, MD, Children's Hospital of Philadelphia

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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 Operative Vaginal Delivery Operative vaginal delivery involves application of forceps or a vacuum extractor to the fetal head to assist during the second stage of labor and facilitate delivery. Indications for forceps... read more , or cesarean delivery Cesarean Delivery Cesarean delivery is surgical delivery by incision into the uterus. The rate of cesarean delivery was 32% in the United States in 2021 (see March of Dimes: Delivery Method). The rate has fluctuated... read more .

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 transverse 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 Preterm Labor Labor (regular uterine contractions resulting in cervical change) that begins before 37 weeks gestation is considered preterm. Risk factors include prelabor rupture of membranes, uterine abnormalities... read more

Multiple gestation Multifetal Pregnancy Multifetal pregnancy is presence of > 1 fetus in the uterus. Multifetal (multiple) pregnancy occurs in up to 1 of 30 deliveries. Risk factors for multiple pregnancy include Ovarian stimulation... read more

Uterine abnormalities

Fetal anomalies

If delivery is vaginal, breech presentation may increase risk of

Umbilical cord prolapse

Perinatal death

It is best to detect abnormal fetal lie or presentation before delivery. During routine prenatal care, clinicians assess fetal lie and presentation with physical examination in the late third trimester. Ultrasonography can also be done. If breech presentation is detected, external cephalic version can sometimes move the fetus to vertex presentation before labor, usually at 37 or 38 weeks. This technique involves gently pressing on the maternal abdomen to reposition the fetus. A dose of a short-acting tocolytic ( terbutaline 0.25 mg subcutaneously) may help. The success rate is about 50 to 75%. For persistent abnormal lie or presentation, cesarean delivery is usually done at 39 weeks or when the woman presents in labor.

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 Operative Vaginal Delivery Operative vaginal delivery involves application of forceps or a vacuum extractor to the fetal head to assist during the second stage of labor and facilitate delivery. Indications for forceps... read more or cesarean delivery Cesarean Delivery Cesarean delivery is surgical delivery by incision into the uterus. The rate of cesarean delivery was 32% in the United States in 2021 (see March of Dimes: Delivery Method). The rate has fluctuated... read more is often required.

Position and Presentation of the Fetus

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

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

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

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Malpresentation and Malposition of the Fetus

A malpresentation or malposition of the fetus is when the fetus is in any abnormal position, other than vertex (head down) with the occiput anterior or posterior.

The following are considered malpresentations or malpositions:

Unstable lie

• Transverse presentation
• Oblique presentation

Face presentation

Brow presentation

Shoulder presentation

High head at term

• Prolapsed arm

The cause of a malpresentation can often not be clearly identified but it can be associated with the following:

• Preterm pregnancy
• Uterine anomalies
• Pelvic tumors eg f ibroids
• Placenta previa
• Grandmultiparty
• Contracted maternal pelvis
• Multiple gestation
• Too much amniotic fluyid (polyhydramnios)
• Short umbilical cord
• Fetal anomalies (e.g. anencephaly, hydro-cephalus)
• Abnormal fetal motor ability

There is an increased risk of neonatal and maternal complications associated with a malpresentation including neonatal and maternal trauma. If delivery is indicated, doing a cesarean delivery can significantly decrease the risk of complications.

Transverse lie

Oblique lie

In most cases of a normal vertex (head down) presentation, the baby's head is flexed with the chin close to the baby's chest. In these cases, the presenting part is the occiput, the posterior part of the baby's head. If the baby's head is more but not completekly extended then the baby's brow presents towards the vagina. A brow presentation is rare, maybe happening in about 1 in 2,000 births, more likely in pwomen with their second or subsequent births. A baby with a brow presentation can only deliver vaginally if the head flexes or extends.

Prolapsed arm 

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ICD-10-CM Coding for Malposition/Malpresentation of Fetus

Mar 27, 2024

Fetal positioning within the uterus is not of much concern until the third trimester which is when most fetuses assume a head down position in preparation for descent into the birth canal. Optimal fetal positioning makes labor and delivery faster, easier and safer for both the fetus and the mother. Fetal malposition or malpresentation may lead to difficulties with labor and delivery and can be an indication for as assisted vaginal birth or delivery by cesarean section. Proper code assignment for malposition and malpresentation is necessary to support performance of these procedures for these conditions.

What is Fetal Presentation, Position and Lie?

Fetal presentation, position and lie describe the fetus in relation to the uterus, cervix and maternal pelvis.

• Fetal presentation refers to the part of the fetus that is lined up to enter the maternal pelvis first/lead the fetus through the cervix (e.g., occiput, chin, shoulder, foot).
• Fetal position refers to the position of the fetal head as it exits the birth canal. This indicates the direction the fetus is facing (anterior, posterior, transverse).
• Fetal lie refers to how the long axis of the fetus (think spinal column) lines up in relation to the uterus. The lie can be longitudinal (straight up and down), oblique (diagonal) or transverse (sideways). 

Normal or optimal presentation, position and lie for vaginal obstetric delivery is:

• Presentation: Vertex/cephalic (the crown of the head) with chin tucked to chest and arms crossed over the chest
• Position: Occiput anterior (the baby is facing toward the mother’s spine)
• Lie: Longitudinal (straight up and down).

What is Malpresentation/Malposition?

Malpresentations and malpositions result when one or a combination of the fetal presentation, position or lie deviates from the normal/optimal status. Below are examples of malpresentations, malpositions, and abnormal lie.

Malpresentation

• Frank breech: Buttocks down with feet near the head
• Complete breech: Knees bent with feet near the buttocks
• Incomplete breech: One knee bent with one foot near the buttocks
• Footling breech: One or both feet are the presenting part
• Face/Brow/Chin (mentum): The fetus’ neck is hyperextended (arched) making the face, brow or chin the presenting fetal part. The degree of hyperextension determines which part is presenting. Greater extension presents the face/chin, less extension presents the brow.
• Shoulder/arm: The shoulder or arm is the presenting part of the fetus
• High head at term: The fetal head does not engage in the pelvis
• Compound: A fetal extremity presents alongside the part of the fetus closest to the birth canal (e.g., hand/arm presents alongside the head)

Malposition

• Occipitoposterior: The fetus’ occiput (back of the head) is against the posterior (spinal) side of the mother and the fetus is facing toward the mother’s abdomen. This is sometimes referred to as “sunny side up”.
• Occipitotransverse: This position is halfway between an anterior and a posterior position. The side of the fetus is perpendicular to the mother’s spine and the fetus is facing outward toward the mother’s right or left thigh. 

Abnormal Lie

• Oblique: The fetus is lying diagonally.
• Transverse: The fetus is lying sideways.
• Unstable: The fetus does not maintain a fixed longitudinal lie after 36 weeks gestation.

How is Malpresentation/Malposition Coded in ICD-10-CM?

Codes for malpresentation and/or malposition of fetus are found in category O32 Maternal care for malpresentation of fetus. Notice that the description of each code specifies that the code is used to report maternal care for a specific type of malpresentation/malposition.

032.0 Maternal care for unstable lie

032.1 Maternal care for breech presentation

• Maternal care for buttocks presentation
• Maternal care for complete breech
• Maternal care for frank breech
• Excludes 1: footling presentation (032.8); incomplete breech (032.8)

032.2 Maternal care for transverse and oblique lie

• Maternal care for oblique presentation
• Maternal care for transverse presentation

032.3 Maternal care for face, brow and chin presentation

032.4 Maternal care for high head at term

• Maternal care for failure of head to enter pelvic brim

032.6 Maternal care for compound presentation

032.8 Maternal care for other malpresentation of fetus

• Maternal care for footling presentation
• Maternal care for incomplete breech

032.9 Maternal care for malpresentation of fetus, unspecified

Assignment of codes is determined by a applying a combination of direction found in the Alphabetic Index, the Tabular List and the ICD-10-CM official guidelines to the documentation in the medical record.

The Alphabetic Index

Selection of the correct code to report malpresentation/malposition is directed by a valid search of the Index to Diseases and Injuries. There are several ways the index can be searched to arrive at codes for malpresentation/malposition depending on the terminology used in the documentation.

Successful searches include:

Delivery  cesarean (for)     breech presentation O32.1    chin presentation O32.3    high head at term O32.4     Etc.

Delivery    complicated       by          malposition, malpresentation             without obstruction                 breech O32.1                 compound O32.6                 face (brow) (chin) O32.3                 footling O32.8       high head O32.4      oblique O32.2      specified NEC O32.8      transverse O32.2      unstable lie O32.0

Delivery    complicated       by          prolapse              arm or hand O32.2              foot or leg O32.8

Failure   descent of head (at term) of pregnancy (mother) O32.4   engagement of head (term of pregnancy) (mother) O32.4

Pregnancy    Complicated by       mentum presentation O32.3        oblique lie or presentation O32.2        transverse lie or presentation O32.2        unstable lie O32.0        Etc.

Pregnancy    Complicated by       presentation, fetal -see Delivery, complicated by, malposition

Breech presentation (mother) O32.1

Transverse     lie (mother) O32.2  

Unstable     lie (mother) O32.0

Presentation, fetal -see Delivery , complicated by, malposition

The Tabular List

There are notes at the beginning of category O32 that provide important direction that must be followed when assigning codes from this category. For example:

• Codes from this category are assigned when malpresentation/malposition is the reason for maternal care
• When malpresentation causes obstructed labor, a code from category O64 is assigned rather than from category O32
• A 7 th character that reports the affected fetus is assigned to codes for malpresentation/malposition

O32 Maternal care for malpresentation of fetus

• Includes: the listed conditions as a reason for observation, hospitalization or other obstetric care of the mother, or for cesarean delivery before onset of labor

Excludes1: malpresentation of fetus with obstructed labor (064.-)

One of the following 7th characters is to be assigned to each code under category 032. 7th character 0 is for single gestations and multiple gestations where the fetus is unspecified. 7th characters 1 through 9 are for cases of multiple gestations to identify the fetus for which the code applies. The appropriate code from category 030, Multiple gestation, must also be assigned when assigning a code from category O32 that has a 7th character of 1 through 9.

• 0 - not applicable or unspecified
• 1 - fetus 1
• 2 - fetus 2
• 3 - fetus 3
• 4 - fetus 4
• 5 - fetus 5
• 9 - other fetus

Note: Codes from category O32 only have 4 characters, so a placeholder character of “X” is needed in the 5 th and 6 th character places to ensure the character value assigned to indicate the affected fetus is in the 7 th character place.

The ICD-10-CM Coding Guidelines

According to ICD-10-CM Official Guideline I.C.15.b.4 Selection of OB Principal or First-listed Diagnosis When a Delivery Occurs , malpresentation/malposition is sequenced as the principal diagnosis when:

• Malpresentation/malposition is the reason for admission.
• Malpresentation/malposition and another condition prompt the admission but malpresentation/malposition is most related to the delivery (e.g., it leads to instrumental vaginal delivery or is the reason for admission for cesarean section)
• The patient is admitted with no other complications of pregnancy and develops malpresentation/malposition post admission and malpresentation/malposition necessitates maternal care including, but not limited to: repositioning of the patient, rotation of fetal head, internal/external version, instrumental vaginal delivery (forceps/vacuum extraction).

In a small number of cases, how the fetus is situated may be a malpresentation/malposition but the malpresentation/malposition does not require maternal care. If this is the case, a code from category O32 is not assigned.

Example: A patient is admitted in advanced premature labor. The fetus is in vertex presentation, but in occiput posterior position (sunny side up). Due to the small size of the fetus, it is delivered via a normal, spontaneous vaginal delivery in the occiput posterior position.

Since the malposition of the fetus did not necessitate maternal care a code from category O32 is not assigned. This is consistent with the coding guidelines for selection of additional or other diagnoses.

Section III. Reporting Additional Diagnoses

GENERAL RULES FOR OTHER (ADDITIONAL) DIAGNOSES

For reporting purposes, the definition for “other diagnoses ” is interpreted as additional clinically significant conditions that affect patient care in terms of requiring:

clinical evaluation; or

therapeutic treatment; or

diagnostic procedures; or

extended length of hospital stay; or

increased nursing care and/or monitoring

Malpresentation/Malposition as an Indication for Cesarean Section

In cases where vaginal delivery is contraindicated because of malpresentation, malposition or abnormal lie, a cesarean section may need to be performed to deliver the fetus safely.

The Includes note under category O32 in the Tabular List indicates codes from this category are intended to be reported when the decision to deliver a patient via cesarean section, secondary to malpresentation or malposition of the fetus, is made before the onset of labor .

This distinction is important because when a patient presents in labor with the intent to delivery vaginally and malpresentation/malposition results in the decision to deliver the patient via cesarean this is typically because the malpresentation/malposition of the fetus has resulted in obstructed labor that precludes vaginal delivery. These circumstances are reported with a code from category O64 Obstructed labor due to malposition and malpresentation of fetus rather than with a code from category O32 .

Malpresentations and malpositions result when one or a combination of the fetal presentation, position or lie deviates from the normal/optimal status. ICD-10-CM codes to report malpresentation/malposition are assigned from category O32 Maternal care for malpresentation of fetus when the malpresentation/malposition is the reason for maternal care. Code selection is guided by documentation in the medical record and a valid search of the Index to Diseases and Injuries. The ICD-10-CM Tabular List and coding guidelines provide significant direction regarding the requirements and structure for assigning a valid code and sequencing of codes from category O32 as the principal diagnosis.

References ICD-10-CM Index to Diseases and Injuries ICD-10-CM Official Guidelines for Coding and Reporting ICD-10-CM Tabular List

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‘Safe Haven’ baby’s family raising money to bring baby box to Palestine

PALESTINE, Texas (KLTV) - In the late ‘90′s, the Texas Legislature introduced HB 3423, known as the Baby Moses or Safe Haven law, that would allow mothers of newborn children to surrender them at local emergency agencies like hospitals, fire departments or police stations without repercussions.

Signed by then-Governor George W. Bush, it became the first legislation of its kind in the U.S.. The law is in response to the growing number of newborn abandonments in the state at the time.

Most recently, in the 88th Texas Legislative session, the laws expanded to include the installation of devices known as Safe Haven Baby Boxes in emergency agencies.

In Texas, Senator Bryan Hughes of Mineola introduced Senate Bill 780 in March of 2023 before heading to the governor’s desk, becoming law in September.

“We’re talking about an alternative to a mother who may be tempted to abandon the child in a ... heaven forbid ... a dumpster, a public restroom or worse,” Hughes said on the Texas Senate floor.

The devices would allow for a more anonymous drop off of the child for mothers, without the face-to-face interaction that most of the situations produce.

The mother places the baby in the box, triggering a silent alarm on the other side to notify emergency personnel that a baby is in the SHBB. Once the mother’s side is closed, it cannot be opened from the outside. The baby is then taken by firefighters, police or hospitals to be looked over by EMT’s before handing the child over to the Department of Family and Protective Services.

The Safe Haven Baby Box project started in Indiana, after the founder Monica Kelsey found out she was left at a hospital by her birth mother. As states implement more Safe Haven laws, the Kelseys worked with officials in law enforcement, as well as other first responders to train and include the addition of baby boxes in emergency personnel-manned areas.

When Senate Bill 780 became law, it caught the attention of Palestine resident Susan “Sue” Tingle, inspiring her to begin her journey to bring a baby box to East Texas.

“So many people, including law enforcement, don’t know even know what a Safe Haven Baby Box is...so that’s bringing awareness to all of that and bringing the community together,” Tingle said.

It’s more special for her family, since her two-year-old granddaughter Myah Faltynski is a Safe Haven Baby Box baby.

“She’s in my heart, she stole it from the minute she came to my daughter,” Tingle said.

Myah’s journey began in the box and ended with her finding a forever home with the Faltynski family.

Without meeting Myah’s birth mother, Shelby Faltynski of Indiana expresses her gratitude towards her and the device for bringing their whole family of four together.

“Myah’s mommy courageously her birth mommy, courageously surrendered her in a safe haven baby box,” Faltynski said. “The Department of Child Services the contacted us and asked if we would be interested in interviewing to adopt a Safe Haven baby.”

Inspired by her daughter’s journey to bring to adopt Myah, she immediately began planning with local officials and first responders, having a history as a first responder herself.

“Safe Haven comes and they decide where the box goes once we get the funding for it so it could either be a hospital, a police station, fire station…someplace that’s manned once the baby is in the box,” Tingle said.

Before the box can call East Texas home, Tingle is raising money through donations and fundraising efforts to bring the baby box to Palestine. The cost to install on of these baby boxes is close to $25,000, which includes the creation of the box and installation from Safe Haven. The donations go straight towards the funding of the project.

On April 6, Tingle is partnering with multiple agencies to put on a fundraising family fair with resources available in Anderson County. The event is free for the public to attend will take place in Reagan Park in Palestine from 6 p.m. to 8 p.m.

Copyright 2024 KLTV. All rights reserved.

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