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क्या ब्रीच स्थिति (गर्भ में बच्चा उल्टा होना) में सामान्य प्रसव संभव है? | Ulta Bacha (Breech Baby) Normal Delivery

प्रेगनेंसी के दौरान अधिकतर गर्भवतियों के मन में यह सवाल जरूर आता है कि उनकी नॉर्मल डिलीवरी होगी या सीजेरियन। वहीं, गर्भावस्था के दौरान अगर सब कुछ सही होता है, तो डॉक्टर महिला की नॉर्मल डिलीवरी को ही प्राथमिकता देते हैं। फिर भी कुछ परिस्थितियां ऐसी पैदा हो जाती है, जिसमें न चाहते हुए भी सी-सेक्शन का निर्णय लेना पड़ता है। ऐसी ही एक स्थिति ब्रीच प्रेगनेंसी (पेट में बच्चा उल्टा होना) है। मॉमजंक्शन के इस लेख में हम पेट में बच्चा उल्टा होने की स्थिति के बारे में ज्यादा से ज्यादा जानकारी देने की कोशिश कर रहे हैं। इसलिए, आप यह लेख अंत तक जरूर पढ़ें।

हम लेख की शुरुआत ब्रीच डिलीवरी के बारे में विस्तृत जानकारी के साथ करते हैं।

ब्रीच डिलीवरी का क्या मतलब होता है?

गर्भावस्था के दौरान गर्भ में शिशु की सबसे अच्छी पोजिशन वो होती है, जब शिशु का सिर नीचे की ओर होता है। इसे सामान्य प्रसव के लिए शिशु की सबसे सुरक्षित अवस्था माना जाता है। इससे प्रसव के दौरान किसी तरह की मुश्किल का जोखिम भी कम हो सकता है। वहीं, जब शिशु की इस पोजिशन में कुछ गड़बड़ या बदलाव होता है, तो उसे ब्रीच कहते हैं। आसान शब्दों में समझा जाए, तो गर्भ में बच्चे की पोजिशन उल्टी होने यानी पैर नीचे की तरफ होने को ब्रीच डिलीवरी कहते हैं (1) (2) ।

आगे लेख में जानिए इसके प्रकार के बारे में।

ब्रीच स्थिति (पेट में बच्चा उल्टा होने) के प्रकार

ब्रीच स्थिति तीन प्रकार के होती है, जो निम्न रूप से है (1) (3) :

• कंपलीट ब्रीच – इसमें बच्चे के दोनों घुटने मुड़े होते हैं और बच्चे के कूल्हे प्रसव नलिका के पास होते हैं। यह पोजिशन ऐसी होती है, जैसे शिशु गर्भ में बैठा हो।
• फ्रैंक ब्रीच – इसमें भी बच्चे के कूल्हे प्रसव नलिका के पास होते हैं, लेकिन बच्चे के पैर ऊपर सिर की तरफ फैले हुए होते हैं।
• इनकंपलीट ब्रीच – इसमें बच्चे के कूल्हे और एक पैर मां के गर्भाशय ग्रीवा के पास होता है और एक पैर ऊपर सिर की तरफ होता है।

नोट : इन तीनों ब्रीच स्थिति के प्रकार में एक बात समान है कि तीनों में शिशु का सिर ऊपर की तरफ और कूल्हे गर्भाशय ग्रीवा के पास होते हैं।

आगे जानते हैं ब्रीच बेबी होने के लक्षणों के बारे में।

गर्भ में बच्चा उल्टा होने के लक्षण

अधिकांश बच्चे गर्भावस्था के आखिरी महीने तक जन्म के लिए तैयार यानी सिर-नीचे की स्थिति में आ जाते हैं। डॉक्टर इसे ‘वर्टेक्स’ (vertex) या ‘सेफेलिक’ (cephalic) स्थिति कहते हैं। गर्भावस्था के 35-36वें सप्ताह के पहले तक शिशु का ब्रीच पोजिशन में होना सामान्य है और जैसे-जैसे प्रसव का वक्त निकट आता है, शिशु धीरे-धीरे सेफेलिक स्थिति में आ जाता है।

असल में गर्भवती को ब्रीच बेबी के लक्षण पता नहीं चल पाते हैं। सिर्फ डॉक्टर ही इसका पता लगा पाते हैं। जब गर्भवती दूसरी और तीसरी तिमाही में जांच के लिए जाती हैं, तो डॉक्टर उसके पेट को छूकर जांच करते हैं, जिसे एब्डोमिनल पालपेशन (abdominal palpation) कहा जाता है।

35-36वें सप्ताह में डॉक्टर गर्भवती के पेट को छूकर जांच करते हैं कि शिशु प्रसव के लिए सेफेलिक पोजिशन में आया है या नहीं। अगर उन्हें संदेह होता है कि बच्चा ब्रीच स्थिति में है, तो वो अल्ट्रासाउंड स्कैन की सलाह दे सकते हैं, ताकि गर्भ में बच्चे की पोजिशन की पुष्टि कर सके (4) ।

लेख के इस भाग में जानिए उल्टा बच्चा होने के कारण।

गर्भ में बच्चा उल्टा होने के कारण

गर्भ में बच्चा उल्टा होने के कारण निम्न प्रकार से हो सकते हैं (1) (4) ।

• अगर गर्भाशय का आकार असामान्य हो।
• पॉलिहाइड्रेमनियोस यानी अधिक एमनियोटिक द्रव हो।
• अगर गर्भ में जुड़वां बच्चे हों।
• प्लेसेंटा प्रिविया (जब प्लेसेंटा गर्भाशय की दीवार के निचले हिस्से पर होता है, तो गर्भाशय ग्रीवा में बाधा हो सकती है)

आगे जानिए प्रेगनेंसी में बच्चा उल्टा होने का पता कैसे लगाया जा सकता है।

प्रेगनेंसी में बच्चा उल्टा होने का निदान

जैसा कि लेख में ऊपर जानकारी दी गई है कि ब्रीच बेबी के बारे में डॉक्टर गर्भवती के पेट को छूकर पता लगाते हैं। इसकी पुष्टि करने के लिए डॉक्टर महिला का अल्ट्रासाउंड स्कैन कर सकते हैं (4) ।

आगे जानिए बच्चा उल्टा होने से होने वाली जटिलताओं के बारे में।

पेट में बच्चा उल्टा होने की जटिलताएं

गर्भावस्था के दौरान पेट में बच्चा उल्टा होने से कुछ समस्याएं हो सकती हैं, जो इस प्रकार हैं (5) (6) :

• ब्रीच डिलीवरी की जटिलताओं की बात की जाए, तो इसमें प्रोलैप्स गर्भनाल (prolapsed umbilical cord) सामान्य है। यह तब होता है, जब गर्भनाल का कुछ हिस्सा शिशु के निकलने से पहले गर्भाशय ग्रीवा से नीचे फिसल जाता है। इस कारण बच्चे तक रक्त प्रवाह में कमी हो सकती है। ऐसे में आपातकालीन सी-सेक्शन की जरूरत हो सकती है।
• इसके अलावा, ब्रीच डिलीवरी में शिशु में स्वास्थ्य समस्या या शिशु की जान को भी खतरा हो सकता है।

लेख के इस भाग में हम गर्भ में शिशु को सही पोजिशन में लाने के बारे में जानकारी देने की कोशिश कर रहे हैं।

बच्चे को पेट में पलटने या सही स्थिति में लाने के लिए क्या करें? | pet me baby ulta ho to kya kare

अगर शिशु 36 या 37वें सप्ताह तक गर्भ में अपनी सही पोजिशन में नहीं आता है, तो डॉक्टर एक्सटर्नल सेफालिक वर्शन (External Cephalic Version- ECV) तकनीक का सहारा ले सकते हैं। यह डॉक्टर द्वारा की जाने वाली प्रक्रिया है। इस प्रक्रिया के पहले डॉक्टर गर्भवती को कुछ दवाइयां या इंजेक्शन दे सकते हैं, जिससे गर्भाशय की मांसपेशियों को आराम मिले और यह प्रक्रिया आसानी से हो सके।

इसमें डॉक्टर अल्ट्रासाउंड के जरिए गर्भ में शिशु की पोजिशन का ध्यान रखते हुए धीरे-धीरे गर्भवती के पेट को दबाते रहते हैं, ताकि शिशु सही पोजिशन में आ सके। इसके साथ ही प्रक्रिया के दौरान डॉक्टर शिशु की दिल की धड़कन पर भी ध्यान देते रहते हैं। ज्यादातर मामलों में यह प्रक्रिया सफल ही रहती है। खासतौर पर तब जब इस प्रक्रिया को गर्भावस्था के 35 से 37वें सप्ताह के भीतर किया जाए। इस समय शिशु थोड़ा छोटा होता है और बच्चे के चारों ओर सबसे अधिक द्रव्य होता है (1) । यह हम स्पष्ट कर दें कि आधुनिक मेडिकल ट्रीटमेंट में इस प्रक्रिया का उपयोग धीरे-धीरे कम हो रहा है।

अब सवाल यह उठता है कि गर्भवती डॉक्टर के पास कब जाएं। लेख के अगले भाग में हम इस बारे में ही जानकारी देने की कोशिश करेंगे।

डॉक्टर के पास कब जाएं

जब जांच या अल्ट्रासाउंड के बाद यह पता चलता है कि पेट में बच्चे की पोजिशन उल्टी है, तो हो सकता है डॉक्टर महिला की स्थिति के अनुसार आगे की प्रक्रिया के बारे में बताए। अगर उन्हें ECV तकनीक अपनानी है या सी-सेक्शन करना है, तो वो उसके लिए एक निर्धारित तिथि बताते हैं। वहीं, इस बीच अगर महिला को गर्भ में शिशु की हलचल में थोड़ी कमी महसूस हो या महिला को चिंता या अवसाद की स्थिति में हो, तो डॉक्टर से राय-परामर्श लें। इसके अलावा, अगर गर्भवती को लगे कि उनकी पानी की थैली फट चुकी है यानी उन्हें द्रव्य का रिसाव महसूस हो, तो बिना देर करते हुए डॉक्टर से संपर्क करें।

अक्सर पूछे जाने वाले सवाल

क्या ब्रीच स्थिति में सामान्य प्रसव संभव है | ulta bacha normal delivery.

जैसा कि हमने जानकारी दी है कि अगर पेट में बच्चा उल्टा होने की बात समय पर पता चलती है, तो डॉक्टर एक्सटर्नल सेफालिक वर्शन (ECV) तकनीक से शिशु को सही पोजिशन में लाने की कोशिश करते हैं। अगर यह प्रक्रिया सफल हो जाए, तो नॉर्मल डिलीवरी की जा सकती है। हालांकि, अगर प्लेसेंटा की पोजिशन या शिशु के आकार में वृद्धि हो गई हो, तो डॉक्टर एक्सटर्नल सेफालिक वर्शन तकनीक नहीं करते हैं (7) । डॉक्टर सीधे सी-सेक्शन की सलाह दे सकते हैं, क्योंकि नॉर्मल डिलीवरी में शिशु को खतरा हो सकता है (1) । इसलिए, सामान्य प्रसव या सी-सेक्शन कराना पूरी तरह गर्भवती और गर्भ में शिशु की पोजिशन पर निर्भर करता है।

ब्रीच बेबी डिलिवरी कैसे की जाती है? | ulta bacha delivery

अगर एक्सटर्नल सेफालिक वर्शन (ECV) तकनीक की गुंजाइश न रहे या इसके बाद भी शिशु ब्रीच पोजिशन में ही रहे, तो डॉक्टर सी-सेक्शन करने की सलाह दे सकते हैं (1) । सी-सेक्शन में डॉक्टर गर्भवती के पेट और गर्भाशय में चीरा लगाकर बच्चे की डिलीवरी करते हैं (8) ।

1. Breech Birth by Medlineplus 2. Medical terms and definitions during pregnancy and birth by Better Health 3. Breech – series—Types of breech presentation by Medlineplus 4. Breech Pregnancy by Pregnancy birth & baby 5. Breech – series—Complications of breech by Medlineplus 6. Labor and birth by Womenshealth 7. Breech presentation and turning the baby by Department of health 8. What is a C-section? by NIH

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

• Variations in Fetal Position and Presentation |

During pregnancy, the fetus can be positioned in many different ways inside the mother's uterus. The fetus may be head up or down or facing the mother's back or front. At first, the fetus can move around easily or shift position as the mother moves. Toward the end of the pregnancy the fetus is larger, has less room to move, and stays in one position. How the fetus is positioned has an important effect on delivery and, for certain positions, a cesarean delivery is necessary. There are medical terms that describe precisely how the fetus is positioned, and identifying the fetal position helps doctors to anticipate potential difficulties during labor and delivery.

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

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

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

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

Head first (called vertex or cephalic presentation)

Facing backward (occiput anterior position)

Spine parallel to mother's spine (longitudinal lie)

Neck bent forward with chin tucked

Arms folded across the chest

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

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

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

The uterus is abnormally shaped or contains growths such as fibroids .

The fetus has a birth defect .

There is more than one fetus (multiple gestation).

Position and Presentation of the Fetus

Variations in Fetal Position and Presentation

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

Occiput posterior position

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

When a fetus faces up, the neck is often straightened rather than bent,which requires more room for the head to pass through the birth canal. Delivery assisted by a vacuum device or forceps or cesarean delivery may be necessary.

Breech presentation

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

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

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

In a first delivery, these problems may occur more frequently because a woman’s tissues have not been stretched by previous deliveries. Because of risk of injury or even death to the baby, cesarean delivery is preferred when the fetus is in breech presentation, unless the doctor is very experienced with and skilled at delivering breech babies or there is not an adequate facility or equipment to safely perform a cesarean delivery.

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

Labor starts too soon (preterm labor).

The uterus is abnormally shaped or contains abnormal growths such as fibroids .

Other presentations

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

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

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

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

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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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• Sonographic diagnosis of fetal head deflexion and the risk of cesarean delivery. [Am J Obstet Gynecol MFM. 2020] Sonographic diagnosis of fetal head deflexion and the risk of cesarean delivery. Bellussi F, Livi A, Cataneo I, Salsi G, Lenzi J, Pilu G. Am J Obstet Gynecol MFM. 2020 Nov; 2(4):100217. Epub 2020 Aug 18.
• Review Sonographic evaluation of the fetal head position and attitude during labor. [Am J Obstet Gynecol. 2024] Review Sonographic evaluation of the fetal head position and attitude during labor. Ghi T, Dall'Asta A. Am J Obstet Gynecol. 2024 Mar; 230(3S):S890-S900. Epub 2023 May 19.
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• Intrapartum sonographic assessment of the fetal head flexion in protracted active phase of labor and association with labor outcome: a multicenter, prospective study. [Am J Obstet Gynecol. 2021] Intrapartum sonographic assessment of the fetal head flexion in protracted active phase of labor and association with labor outcome: a multicenter, prospective study. Dall'Asta A, Rizzo G, Masturzo B, Di Pasquo E, Schera GBL, Morganelli G, Ramirez Zegarra R, Maqina P, Mappa I, Parpinel G, et al. Am J Obstet Gynecol. 2021 Aug; 225(2):171.e1-171.e12. Epub 2021 Mar 4.
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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. 

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• 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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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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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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• I don't blame you for not believing the response you were given. It's simply wrong. @Timur Shtatland is correct. Simply put, the uterus can expand more (so is larger) at the top, where there are no bones, than the bottom, which is surrounded by ligaments and the bony pelvis. As the bottom half of a baby (buttocks and legs) is larger than the shoulders and arms, and the head smaller yet than those, the head-first presentation is pysiological, and most common. –  anongoodnurse Commented Mar 24, 2021 at 16:19

Vertex presentation is caused by the shape of the uterus, rather than (directly) caused by gravity.

REFERENCES:

In vertex presentations the head of the fetus most commonly faces to the right and slightly to the rear. This position is said to be the most usual one because the fetus is thus best accommodated to the shape of the uterus.

Presentation | childbirth | Britannica: https://www.britannica.com/science/presentation#ref55860

The piriform (pear-shaped) morphology of the uterus has been given as the major cause for the finding that most singletons favor the cephalic presentation at term.

Cephalic presentation - Wikipedia: https://en.wikipedia.org/wiki/Cephalic_presentation

In about 95% of deliveries, the part of the fetus which arrives first at the mother’s pelvic brim is the highest part of the fetal head, which is called the vertex. This presentation is called the vertex presentation. Notice that the baby’s chin is tucked down towards its chest, so that the vertex is the leading part entering the mother’s pelvis. The baby’s head is said to be ‘well-flexed’ in this position. During early pregnancy, the baby is the other way up — with its bottom pointing down towards the mother’s cervix — which is called the breech presentation. This is because during its early development, the head of the fetus is bigger than its buttocks; so in the majority of cases, the head occupies the widest cavity, i.e. the fundus (rounded top) of the uterus. As the fetus grows larger, the buttocks become bigger than the head and the baby spontaneously reverses its position, so its buttocks occupy the fundus. In short, in early pregnancy, the majority of fetuses are in the breech presentation and later in pregnancy most of them make a spontaneous transition to the vertex presentation.

The Open University: Labour and Delivery Care Module: 8. Abnormal Presentations and Multiple Pregnancies: https://www.open.edu/openlearncreate/mod/oucontent/view.php?id=276&printable=1

• Thank you, this is lovely. –  superAnnoyingUser Commented Mar 24, 2021 at 16:49

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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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4 years ago

Q: Vertex presentation ??Means Is that mean baby in cephalic position or not ?

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