term for vertex presentation

Last updated: Feb 14, 2023

Fetal Lie and Presentation

Presenting diameter, management of cephalic and compound presentations, risks and management of breech and transverse presentations.

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• The “presenting part” refers to the part of the baby that will come through the cervix Cervix The uterus, cervix, and fallopian tubes are part of the internal female reproductive system. The most inferior portion of the uterus is the cervix, which connects the uterine cavity to the vagina. Externally, the cervix is lined by stratified squamous cells; however, the cervical canal is lined by columnar epithelium. Uterus, Cervix, and Fallopian Tubes: Anatomy first. 
• The position refers to how that body part (and thus the baby) is oriented within the maternal pelvis Pelvis The pelvis consists of the bony pelvic girdle, the muscular and ligamentous pelvic floor, and the pelvic cavity, which contains viscera, vessels, and multiple nerves and muscles. The pelvic girdle, composed of 2 “hip” bones and the sacrum, is a ring-like bony structure of the axial skeleton that links the vertebral column with the lower extremities. Pelvis: Anatomy . 
• The uterine fundus Fundus The superior portion of the body of the stomach above the level of the cardiac notch. Stomach: Anatomy is typically roomier, so babies tend to orient themselves head down so that their body and limbs occupy the larger portion of the uterus Uterus The uterus, cervix, and fallopian tubes are part of the internal female reproductive system. The uterus has a thick wall made of smooth muscle (the myometrium) and an inner mucosal layer (the endometrium). The most inferior portion of the uterus is the cervix, which connects the uterine cavity to the vagina. Uterus, Cervix, and Fallopian Tubes: Anatomy .

Clinical relevance

• The maternal pelvis Pelvis The pelvis consists of the bony pelvic girdle, the muscular and ligamentous pelvic floor, and the pelvic cavity, which contains viscera, vessels, and multiple nerves and muscles. The pelvic girdle, composed of 2 “hip” bones and the sacrum, is a ring-like bony structure of the axial skeleton that links the vertebral column with the lower extremities. Pelvis: Anatomy has a diameter of about 10 cm, through which the fetus must pass.
• The presentation and position of the fetus will determine how wide the fetus is (known as the “presenting fetal diameter”) as it attempts to pass through the maternal pelvis Pelvis The pelvis consists of the bony pelvic girdle, the muscular and ligamentous pelvic floor, and the pelvic cavity, which contains viscera, vessels, and multiple nerves and muscles. The pelvic girdle, composed of 2 “hip” bones and the sacrum, is a ring-like bony structure of the axial skeleton that links the vertebral column with the lower extremities. Pelvis: Anatomy .
• Certain presentation/positions are more difficult (or even impossible) to pass through the pelvis Pelvis The pelvis consists of the bony pelvic girdle, the muscular and ligamentous pelvic floor, and the pelvic cavity, which contains viscera, vessels, and multiple nerves and muscles. The pelvic girdle, composed of 2 “hip” bones and the sacrum, is a ring-like bony structure of the axial skeleton that links the vertebral column with the lower extremities. Pelvis: Anatomy because of their large presenting diameter.
• Knowledge of the presentation and position are required to safely manage labor and delivery.

Risk factors for fetal malpresentation

• Multiparity (which can result in lax abdominal walls)
• Multiple gestations (e.g., twins)
• Prematurity Prematurity Neonatal Respiratory Distress Syndrome
• Uterine abnormalities (e.g., leiomyomas, uterine septa)
• Narrow pelvis Pelvis The pelvis consists of the bony pelvic girdle, the muscular and ligamentous pelvic floor, and the pelvic cavity, which contains viscera, vessels, and multiple nerves and muscles. The pelvic girdle, composed of 2 “hip” bones and the sacrum, is a ring-like bony structure of the axial skeleton that links the vertebral column with the lower extremities. Pelvis: Anatomy shapes
• Fetal anomalies (e.g., hydrocephalus Hydrocephalus Excessive accumulation of cerebrospinal fluid within the cranium which may be associated with dilation of cerebral ventricles, intracranial. Subarachnoid Hemorrhage )
• Placental anomalies (e.g.,   placenta previa Placenta Previa Abnormal placentation in which the placenta implants in the lower segment of the uterus (the zone of dilation) and may cover part or all of the opening of the cervix. It is often associated with serious antepartum bleeding and premature labor. Placental Abnormalities , in which the placenta Placenta A highly vascularized mammalian fetal-maternal organ and major site of transport of oxygen, nutrients, and fetal waste products. It includes a fetal portion (chorionic villi) derived from trophoblasts and a maternal portion (decidua) derived from the uterine endometrium. The placenta produces an array of steroid, protein and peptide hormones (placental hormones). Placenta, Umbilical Cord, and Amniotic Cavity covers the internal cervical os)
• Polyhydramnios Polyhydramnios Polyhydramnios is a pathological excess of amniotic fluid. Common causes of polyhydramnios include fetal anomalies, gestational diabetes, multiple gestations, and congenital infections. Patients are often asymptomatic but may present with dyspnea, extremity swelling, or abdominal distention. Polyhydramnios (too much fluid)
• Oligohydramnios Oligohydramnios Oligohydramnios refers to amniotic fluid volume less than expected for the current gestational age. Oligohydramnios is diagnosed by ultrasound and defined as an amniotic fluid index (AFI) of ‰¤ 5 cm or a single deep pocket (SDP) of Oligohydramnios (not enough fluid)
• Malpresentation in a previous pregnancy Pregnancy The status during which female mammals carry their developing young (embryos or fetuses) in utero before birth, beginning from fertilization to birth. Pregnancy: Diagnosis, Physiology, and Care

Epidemiology

Prevalence Prevalence The total number of cases of a given disease in a specified population at a designated time. It is differentiated from incidence, which refers to the number of new cases in the population at a given time. Measures of Disease Frequency rates for different malpresentations at term:

• Vertex presentation, occiput posterior position: 1 in 19 deliveries
• Breech presentation: 1 in 33 deliveries
• Face presentation: 1 in 600–800 deliveries
• Transverse lie: 1 in 833 deliveries
• Compound presentation: 1 in 1500 deliveries 

Related videos

Fetal lie is how the long axis of the fetus is oriented in relation to the mother. Possible lies include:

• Longitudinal: fetus and mother have the same vertical axis (their spines are parallel).
• Transverse: fetal vertical axis is at a 90-degree angle to mother’s vertical axis (their spines are perpendicular).
• Oblique: fetal vertical axis is at a 45-degree angle to mother’s vertical axis (unstable, and will resolve to longitudinal or transverse during labor).

Presentation

Presentation describes which body part of the fetus will pass through the cervix Cervix The uterus, cervix, and fallopian tubes are part of the internal female reproductive system. The most inferior portion of the uterus is the cervix, which connects the uterine cavity to the vagina. Externally, the cervix is lined by stratified squamous cells; however, the cervical canal is lined by columnar epithelium. Uterus, Cervix, and Fallopian Tubes: Anatomy first. Presentations include:

• Cephalic: head down
• Breech: bottom/feet down
• Transverse presentation: shoulder 
• Compound presentation: an extremity presents alongside the primary presenting part

Cephalic presentations

Cephalic presentations can be categorized as:

• Vertex presentation: chin Chin The anatomical frontal portion of the mandible, also known as the mentum, that contains the line of fusion of the two separate halves of the mandible (symphysis menti). This line of fusion divides inferiorly to enclose a triangular area called the mental protuberance. On each side, inferior to the second premolar tooth, is the mental foramen for the passage of blood vessels and a nerve. Melasma flexed, with the occipital Occipital Part of the back and base of the cranium that encloses the foramen magnum. Skull: Anatomy fontanel as the presenting part
• Face presentation
• Brow presentation: forehead Forehead The part of the face above the eyes. Melasma is the presenting part

Vertex presentation

Face presentation (mentum anterior position)

Brow presentation (mentum posterior position)

Breech presentations

Breech presentations can be categorized as:

• Frank breech: bottom down, legs extended (50%–70%) 
• Complete breech: bottom down, hips and knees both flexed
• Incomplete breech: 1 or both hips not completely flexed
• Footling breech: feet down

Breech presentations: Frank (bottom down, legs extended), complete (bottom down, hips and knees both flexed), and footling (feet down) breech presentations

Transverse and compound presentations

• Uncommon, but when they occur, the presenting fetal part is the shoulder.
• If the cervix Cervix The uterus, cervix, and fallopian tubes are part of the internal female reproductive system. The most inferior portion of the uterus is the cervix, which connects the uterine cavity to the vagina. Externally, the cervix is lined by stratified squamous cells; however, the cervical canal is lined by columnar epithelium. Uterus, Cervix, and Fallopian Tubes: Anatomy begins dilating, the arm Arm The arm, or “upper arm” in common usage, is the region of the upper limb that extends from the shoulder to the elbow joint and connects inferiorly to the forearm through the cubital fossa. It is divided into 2 fascial compartments (anterior and posterior). Arm: Anatomy may prolapse through the cervix Cervix The uterus, cervix, and fallopian tubes are part of the internal female reproductive system. The most inferior portion of the uterus is the cervix, which connects the uterine cavity to the vagina. Externally, the cervix is lined by stratified squamous cells; however, the cervical canal is lined by columnar epithelium. Uterus, Cervix, and Fallopian Tubes: Anatomy .
• In compound presentations, the most common situation is a hand Hand The hand constitutes the distal part of the upper limb and provides the fine, precise movements needed in activities of daily living. It consists of 5 metacarpal bones and 14 phalanges, as well as numerous muscles innervated by the median and ulnar nerves. Hand: Anatomy or arm Arm The arm, or “upper arm” in common usage, is the region of the upper limb that extends from the shoulder to the elbow joint and connects inferiorly to the forearm through the cubital fossa. It is divided into 2 fascial compartments (anterior and posterior). Arm: Anatomy presenting with the head.

Shoulder presentation (transverse lie)

Neglected shoulder presentation resulting in arm prolapse during labor

Vertex presentation with a compound hand

Fetal malpresentation

• Any presentation other than vertex
• Clinically, this means breech, face, brow, and shoulder presentations.

Position describes the relation of the fetal presenting part to the maternal bony pelvis Pelvis The pelvis consists of the bony pelvic girdle, the muscular and ligamentous pelvic floor, and the pelvic cavity, which contains viscera, vessels, and multiple nerves and muscles. The pelvic girdle, composed of 2 “hip” bones and the sacrum, is a ring-like bony structure of the axial skeleton that links the vertebral column with the lower extremities. Pelvis: Anatomy .

Vertex positions

Positions for vertex presentations describe the position of the fetal occiput .

• Identified on cervical exam as the area in the midline between the anterior and posterior fontanelles Fontanelles Physical Examination of the Newborn
• Anterior, posterior, or transverse in relation to the maternal pelvis Pelvis The pelvis consists of the bony pelvic girdle, the muscular and ligamentous pelvic floor, and the pelvic cavity, which contains viscera, vessels, and multiple nerves and muscles. The pelvic girdle, composed of 2 “hip” bones and the sacrum, is a ring-like bony structure of the axial skeleton that links the vertebral column with the lower extremities. Pelvis: Anatomy
• Being on the maternal right or left
• Right or left occiput anterior
• Right or left occiput posterior
• Right or left occiput transverse
• Direct occiput anterior or posterior
• The most common positions (and easiest for vaginal delivery) are occiput anterior.

Overview of different vertex positions LOA: left occiput anterior LOP: left occiput posterior LOT: left occiput transverse OA occiput anterior OP: occiput posterior ROA: right occiput anterior ROP: right occiput posterior ROT: right occiput transverse

Face and brow positions

Positions for face and brow presentations describe the position of the chin Chin The anatomical frontal portion of the mandible, also known as the mentum, that contains the line of fusion of the two separate halves of the mandible (symphysis menti). This line of fusion divides inferiorly to enclose a triangular area called the mental protuberance. On each side, inferior to the second premolar tooth, is the mental foramen for the passage of blood vessels and a nerve. Melasma .

• The chin Chin The anatomical frontal portion of the mandible, also known as the mentum, that contains the line of fusion of the two separate halves of the mandible (symphysis menti). This line of fusion divides inferiorly to enclose a triangular area called the mental protuberance. On each side, inferior to the second premolar tooth, is the mental foramen for the passage of blood vessels and a nerve. Melasma is referred to as the mentum.
• Right or left mentum anterior
• Right or left mentum posterior
• Right or left mentum transverse
• Direct mentum anterior or posterior

Face presentation (mentum posterior position)

Breech and shoulder positions

• Positions for breech presentations describe the position of the sacrum Sacrum Five fused vertebrae forming a triangle-shaped structure at the back of the pelvis. It articulates superiorly with the lumbar vertebrae, inferiorly with the coccyx, and anteriorly with the ilium of the pelvis. The sacrum strengthens and stabilizes the pelvis. Vertebral Column: Anatomy . Similar to other presentations, they include anterior, posterior, and transverse and right, left, and direct.
• Dorso-superior (back up)
• Dorso-inferior (back down)

Dorso-inferior shoulder presentation

Dorso-superior shoulder presentation

Attitude and asynclitism

• Attitude: amount of flexion Flexion Examination of the Upper Limbs or extension Extension Examination of the Upper Limbs of the fetal head
• Lateral deflection of the sagittal Sagittal Computed Tomography (CT) suture to 1 side or the other
• Mild degrees of asynclitism are normal.
• More severe asynclitism increases the presenting fetal diameter and makes it more difficult for the fetal head to pass through the maternal pelvis Pelvis The pelvis consists of the bony pelvic girdle, the muscular and ligamentous pelvic floor, and the pelvic cavity, which contains viscera, vessels, and multiple nerves and muscles. The pelvic girdle, composed of 2 “hip” bones and the sacrum, is a ring-like bony structure of the axial skeleton that links the vertebral column with the lower extremities. Pelvis: Anatomy .

Fetal malposition

• Commonly refers to any position other than right occiput anterior, left occiput anterior, or direct occiput anterior
• All nonvertex presentations are also malpositioned.
• The terms fetal malpresentation and fetal malposition are often used interchangeably.
• The presenting diameter refers to the width of the presenting part.
• The maternal pelvis Pelvis The pelvis consists of the bony pelvic girdle, the muscular and ligamentous pelvic floor, and the pelvic cavity, which contains viscera, vessels, and multiple nerves and muscles. The pelvic girdle, composed of 2 “hip” bones and the sacrum, is a ring-like bony structure of the axial skeleton that links the vertebral column with the lower extremities. Pelvis: Anatomy is about 10 cm at its narrowest point; the infant must orient itself so that it can fit through.
• Most commonly, the infant will move into a cephalic, vertex presentation, in 1 of the occiput anterior positions → presents the narrowest diameter
• Vertex presentation: suboccipitobregmatic diameter, approximately 9.5 cm
• Vertex presentation with deflexed head: occipitofrontal diameter, approximately 11.5 cm
• Brow presentation: occipitomental diameter, approximately 13 cm
• Face presentation: submentobregmatic diameter, approximately 9.5 cm

Diameters of the fetal head

Comparison of presentation, attitude, and presenting diameter

How to establish lie, presentation, and position

Delivery is managed differently depending on the presentation and position of the infant. This information can be established in several different ways:

Leopold’s maneuvers

Ultrasonography.

• Cervical examination
• Techniques using abdominal palpation Abdominal Palpation Abdominal Examination to determine the presentation of the fetus
• The fetal head will be hard and round.
• The lower body will be bulkier, nodular, and mobile.
• The back will be hard and smooth.
• The other side (anterior surface of the fetus) will be filled with irregular, mobile fetal parts.
• Experienced providers can also estimate the fetal weight using these maneuvers.
• Bedside abdominal ultrasonography can easily identify the fetal head and its orientation Orientation Awareness of oneself in relation to time, place and person. Psychiatric Assessment .
• Quick bedside ultrasonography Bedside Ultrasonography ACES and RUSH: Resuscitation Ultrasound Protocols on admission to labor and delivery to assess fetal presentation is considered standard of care Standard of care The minimum acceptable patient care, based on statutes, court decisions, policies, or professional guidelines. Malpractice .
• The fetal head will typically encompass the entire window and appear like a large white circle (the fetal skull Skull The skull (cranium) is the skeletal structure of the head supporting the face and forming a protective cavity for the brain. The skull consists of 22 bones divided into the viscerocranium (facial skeleton) and the neurocranium. Skull: Anatomy ).
• Identification Identification Defense Mechanisms of the eyes can help determine position.
• It is quick and easy to perform and presents minimal risk to mother and infant.
• Allowing mothers to labor with infants in a noncephalic presentation significantly increases the risks to both of them.

Suprapubic bedside ultrasound showing the large white circle of the fetal skull, confirming a cephalic presentation F: fetal falx

Vaginal and cervical examination

• As the cervix Cervix The uterus, cervix, and fallopian tubes are part of the internal female reproductive system. The most inferior portion of the uterus is the cervix, which connects the uterine cavity to the vagina. Externally, the cervix is lined by stratified squamous cells; however, the cervical canal is lined by columnar epithelium. Uterus, Cervix, and Fallopian Tubes: Anatomy dilates, the fetal fontanelles Fontanelles Physical Examination of the Newborn can be directly palpated.
• Identifying the location of the fetal fontanelles Fontanelles Physical Examination of the Newborn allows the practitioner to establish the position.
• Insert 1–2 fingers through the cervix Cervix The uterus, cervix, and fallopian tubes are part of the internal female reproductive system. The most inferior portion of the uterus is the cervix, which connects the uterine cavity to the vagina. Externally, the cervix is lined by stratified squamous cells; however, the cervical canal is lined by columnar epithelium. Uterus, Cervix, and Fallopian Tubes: Anatomy posteriorly.
• Sweep fingers along the fetal head moving anteriorly.
• This maneuver allows for identification Identification Defense Mechanisms of the sagittal Sagittal Computed Tomography (CT) suture.
• The fontanelles Fontanelles Physical Examination of the Newborn are then identified by moving along the sagittal Sagittal Computed Tomography (CT) suture.

Vertex presentations

• Expectant management
• All have high chances of successful vaginal delivery.

Compound presentations

• Observation when labor is progressing normally (many compound presentations will resolve spontaneously intrapartum).
• Can attempt to gently pinch the compound extremity trying to provoke the fetus into withdrawing the part (no good quality Quality Activities and programs intended to assure or improve the quality of care in either a defined medical setting or a program. The concept includes the assessment or evaluation of the quality of care; identification of problems or shortcomings in the delivery of care; designing activities to overcome these deficiencies; and follow-up monitoring to ensure effectiveness of corrective steps. Quality Measurement and Improvement evidence, but unlikely to be harmful)
• Can attempt to manually replace the compound extremity
• If labor is prolonged and the compound part remains, cesarean delivery Cesarean Delivery Cesarean delivery (CD) is the operative delivery of ≥ 1 infants through a surgical incision in the maternal abdomen and uterus. Cesarean deliveries may be indicated for a number of either maternal or fetal reasons, most commonly including fetal intolerance to labor, arrest of labor, a history of prior uterine surgery, fetal malpresentation, and placental abnormalities. Cesarean Delivery (CD) should be performed.
• Prolonged labor
• Umbilical cord Umbilical cord The flexible rope-like structure that connects a developing fetus to the placenta in mammals. The cord contains blood vessels which carry oxygen and nutrients from the mother to the fetus and waste products away from the fetus. Placenta, Umbilical Cord, and Amniotic Cavity prolapse
• Increased maternal morbidity Morbidity The proportion of patients with a particular disease during a given year per given unit of population. Measures of Health Status from lacerations
• Ischemia Ischemia A hypoperfusion of the blood through an organ or tissue caused by a pathologic constriction or obstruction of its blood vessels, or an absence of blood circulation. Ischemic Cell Damage of the compound part

Brow presentations

• The majority spontaneously convert to a vertex presentation.
• Cesarean delivery Cesarean Delivery Cesarean delivery (CD) is the operative delivery of ≥ 1 infants through a surgical incision in the maternal abdomen and uterus. Cesarean deliveries may be indicated for a number of either maternal or fetal reasons, most commonly including fetal intolerance to labor, arrest of labor, a history of prior uterine surgery, fetal malpresentation, and placental abnormalities. Cesarean Delivery may be required if labor is prolonged.

Face presentations

• Management depends on the position.
• Can be delivered vaginally by an experienced provider
• Cesarean delivery Cesarean Delivery Cesarean delivery (CD) is the operative delivery of ≥ 1 infants through a surgical incision in the maternal abdomen and uterus. Cesarean deliveries may be indicated for a number of either maternal or fetal reasons, most commonly including fetal intolerance to labor, arrest of labor, a history of prior uterine surgery, fetal malpresentation, and placental abnormalities. Cesarean Delivery may be required.
• Head is fully extended and unable to pass through the birth canal Birth canal Pelvis: Anatomy .
• Normally, the fetal head flexes as it passes under the pubic bone Bone Bone is a compact type of hardened connective tissue composed of bone cells, membranes, an extracellular mineralized matrix, and central bone marrow. The 2 primary types of bone are compact and spongy. Bones: Structure and Types ; however, this is impossible in an MP position.
• Cesarean delivery Cesarean Delivery Cesarean delivery (CD) is the operative delivery of ≥ 1 infants through a surgical incision in the maternal abdomen and uterus. Cesarean deliveries may be indicated for a number of either maternal or fetal reasons, most commonly including fetal intolerance to labor, arrest of labor, a history of prior uterine surgery, fetal malpresentation, and placental abnormalities. Cesarean Delivery is always required (unless the infant spontaneously rotates to a mentum anterior (MA) position).

There are 3 primary options for managing breech presentations: performing CD, attempting an external cephalic version to manually rotate the baby into a vertex presentation for attempted vaginal delivery, or a planned vaginal breech delivery (which is generally not done in the United States).

Natural history of breech presentations

Most infants will spontaneously rotate to a vertex presentation as the pregnancy Pregnancy The status during which female mammals carry their developing young (embryos or fetuses) in utero before birth, beginning from fertilization to birth. Pregnancy: Diagnosis, Physiology, and Care progresses. At different gestational ages, the prevalence Prevalence The total number of cases of a given disease in a specified population at a designated time. It is differentiated from incidence, which refers to the number of new cases in the population at a given time. Measures of Disease Frequency of breech presentations is:

• < 28 weeks: 20%–25%
• 32 weeks: 10%–15%
• Term (> 37 weeks): 3% 
• Spontaneous version is possible even at > 40 weeks.
• Flexed fetal legs
• Polyhydramnios Polyhydramnios Polyhydramnios is a pathological excess of amniotic fluid. Common causes of polyhydramnios include fetal anomalies, gestational diabetes, multiple gestations, and congenital infections. Patients are often asymptomatic but may present with dyspnea, extremity swelling, or abdominal distention. Polyhydramnios
• Longer umbilical cord Umbilical cord The flexible rope-like structure that connects a developing fetus to the placenta in mammals. The cord contains blood vessels which carry oxygen and nutrients from the mother to the fetus and waste products away from the fetus. Placenta, Umbilical Cord, and Amniotic Cavity
• Lack of fetal/uterine anomalies
• Multiparity

Fetal risks associated with breech presentations

The following risks are associated with breech presentations in utero, regardless of mode of delivery:

• ↑ Association with congenital Congenital Chorioretinitis malformations
• Torticollis Torticollis A symptom, not a disease, of a twisted neck. In most instances, the head is tipped toward one side and the chin rotated toward the other. The involuntary muscle contractions in the neck region of patients with torticollis can be due to congenital defects, trauma, inflammation, tumors, and neurological or other factors. Cranial Nerve Palsies
• Developmental hip dysplasia 

Fetal risks associated with vaginal breech delivery

The primary risk of a vaginal breech delivery is fetal head entrapment:

• The fetal body delivers, but the head remains trapped in the uterus Uterus The uterus, cervix, and fallopian tubes are part of the internal female reproductive system. The uterus has a thick wall made of smooth muscle (the myometrium) and an inner mucosal layer (the endometrium). The most inferior portion of the uterus is the cervix, which connects the uterine cavity to the vagina. Uterus, Cervix, and Fallopian Tubes: Anatomy .
• Causes compression Compression Blunt Chest Trauma of the umbilical cord Umbilical cord The flexible rope-like structure that connects a developing fetus to the placenta in mammals. The cord contains blood vessels which carry oxygen and nutrients from the mother to the fetus and waste products away from the fetus. Placenta, Umbilical Cord, and Amniotic Cavity running past the head (between the delivered umbilicus and the undelivered placenta Placenta A highly vascularized mammalian fetal-maternal organ and major site of transport of oxygen, nutrients, and fetal waste products. It includes a fetal portion (chorionic villi) derived from trophoblasts and a maternal portion (decidua) derived from the uterine endometrium. The placenta produces an array of steroid, protein and peptide hormones (placental hormones). Placenta, Umbilical Cord, and Amniotic Cavity ) 
• Leads to hypoxia Hypoxia Sub-optimal oxygen levels in the ambient air of living organisms. Ischemic Cell Damage until head is delivered → ↑ risk of fetal death
• The cervix Cervix The uterus, cervix, and fallopian tubes are part of the internal female reproductive system. The most inferior portion of the uterus is the cervix, which connects the uterine cavity to the vagina. Externally, the cervix is lined by stratified squamous cells; however, the cervical canal is lined by columnar epithelium. Uterus, Cervix, and Fallopian Tubes: Anatomy may not be fully dilated enough to accommodate the head.
• The fetal head may not fit through the bony pelvis Pelvis The pelvis consists of the bony pelvic girdle, the muscular and ligamentous pelvic floor, and the pelvic cavity, which contains viscera, vessels, and multiple nerves and muscles. The pelvic girdle, composed of 2 “hip” bones and the sacrum, is a ring-like bony structure of the axial skeleton that links the vertebral column with the lower extremities. Pelvis: Anatomy .
• The mother’s expulsive efforts are unable to quickly deliver the head.
• Umbilical cord Umbilical cord The flexible rope-like structure that connects a developing fetus to the placenta in mammals. The cord contains blood vessels which carry oxygen and nutrients from the mother to the fetus and waste products away from the fetus. Placenta, Umbilical Cord, and Amniotic Cavity prolapse during labor → requires emergent CD
• Birth injuries to the fetus (e.g., brachial plexus Brachial Plexus The large network of nerve fibers which distributes the innervation of the upper extremity. The brachial plexus extends from the neck into the axilla. In humans, the nerves of the plexus usually originate from the lower cervical and the first thoracic spinal cord segments (c5-c8 and T1), but variations are not uncommon. Peripheral Nerve Injuries in the Cervicothoracic Region injury)

Vaginal breech delivery

Vaginal breech deliveries for singleton gestations may be considered for certain low-risk women if vaginal delivery is strongly desired by the mother. In contrast, vaginal breech deliveries are done frequently for breech 2nd twins; the procedure is known as a breech extraction.

• Mothers must be fully counseled on risks.
• Mothers and infants should be monitored throughout labor with continuous electronic fetal heart rate Heart rate The number of times the heart ventricles contract per unit of time, usually per minute. Cardiac Physiology (FHR) and tocometry monitors.
• Mothers should understand that a CD will be recommended if there are signs of fetal distress or prolonged labor.
• Avoid artificial rupture of membranes to ↓ risk of cord prolapse.
• Frank or complete breech presentation with no hyperextension of the fetal head on ultrasonography
• No contraindications Contraindications A condition or factor associated with a recipient that makes the use of a drug, procedure, or physical agent improper or inadvisable. Contraindications may be absolute (life threatening) or relative (higher risk of complications in which benefits may outweigh risks). Noninvasive Ventilation to a vaginal birth
• No prior CDs
• Prior successful vaginal deliveries (i.e., multiparity)
• Gestational age Gestational age The age of the conceptus, beginning from the time of fertilization. In clinical obstetrics, the gestational age is often estimated as the time from the last day of the last menstruation which is about 2 weeks before ovulation and fertilization. Pregnancy: Diagnosis, Physiology, and Care ≥ 36 weeks
• Spontaneous labor
• Normal bony pelvis Pelvis The pelvis consists of the bony pelvic girdle, the muscular and ligamentous pelvic floor, and the pelvic cavity, which contains viscera, vessels, and multiple nerves and muscles. The pelvic girdle, composed of 2 “hip” bones and the sacrum, is a ring-like bony structure of the axial skeleton that links the vertebral column with the lower extremities. Pelvis: Anatomy shown on X-ray X-ray Penetrating electromagnetic radiation emitted when the inner orbital electrons of an atom are excited and release radiant energy. X-ray wavelengths range from 1 pm to 10 nm. Hard x-rays are the higher energy, shorter wavelength x-rays. Soft x-rays or grenz rays are less energetic and longer in wavelength. The short wavelength end of the x-ray spectrum overlaps the gamma rays wavelength range. The distinction between gamma rays and x-rays is based on their radiation source. Pulmonary Function Tests
• Estimated fetal weight Estimated Fetal Weight Obstetric Imaging between approximately 2500 and 3500 grams (exact range varies based on clinician Clinician A physician, nurse practitioner, physician assistant, or another health professional who is directly involved in patient care and has a professional relationship with patients. Clinician–Patient Relationship )
• Immediately after delivery of the 1st twin in the cephalic presentation, the physician reaches up into the uterus Uterus The uterus, cervix, and fallopian tubes are part of the internal female reproductive system. The uterus has a thick wall made of smooth muscle (the myometrium) and an inner mucosal layer (the endometrium). The most inferior portion of the uterus is the cervix, which connects the uterine cavity to the vagina. Uterus, Cervix, and Fallopian Tubes: Anatomy , manually grabs the infant’s legs, and gently guides them down through the birth canal Birth canal Pelvis: Anatomy while the cervix Cervix The uterus, cervix, and fallopian tubes are part of the internal female reproductive system. The most inferior portion of the uterus is the cervix, which connects the uterine cavity to the vagina. Externally, the cervix is lined by stratified squamous cells; however, the cervical canal is lined by columnar epithelium. Uterus, Cervix, and Fallopian Tubes: Anatomy is still fully dilated.
• ↓ Risk of head entrapment compared to singleton vaginal breech deliveries

External cephalic version

An external cephalic version (ECV) is a procedure in which the physician attempts to manually rotate the fetus from a breech to a cephalic presentation by pushing on the maternal abdomen.

• Approximately 50%–60% (higher in multiparous Multiparous A woman with prior deliveries Normal and Abnormal Labor than in nulliparous women) 
• 97% of infants remained cephalic at birth.
• 86% delivered vaginally.
• Women who are candidates for ECV should be counseled on their options to attempt an ECV, or they may simply elect to schedule a CD.
• Infant is full term in case emergent CD is required because of complications from the procedure (e.g., placental abruption Placental Abruption Premature separation of the normally implanted placenta from the uterus. Signs of varying degree of severity include uterine bleeding, uterine muscle hypertonia, and fetal distress or fetal death. Antepartum Hemorrhage ).
• Better ratio of infant size to fluid level than later in pregnancy Pregnancy The status during which female mammals carry their developing young (embryos or fetuses) in utero before birth, beginning from fertilization to birth. Pregnancy: Diagnosis, Physiology, and Care
• Allows infant more time for spontaneous version than if the procedure was done earlier
• After a successful version, the mother can await spontaneous labor or be induced immediately, depending on the situation.
• There is still a chance that the infant may spontaneously rotate between the failed ECV and the planned CD date; therefore, presentation should always be checked immediately prior to CD.
• Another contraindication for a vaginal delivery (e.g., placenta previa Placenta Previa Abnormal placentation in which the placenta implants in the lower segment of the uterus (the zone of dilation) and may cover part or all of the opening of the cervix. It is often associated with serious antepartum bleeding and premature labor. Placental Abnormalities )
• Severe oligohydramnios Oligohydramnios Oligohydramnios refers to amniotic fluid volume less than expected for the current gestational age. Oligohydramnios is diagnosed by ultrasound and defined as an amniotic fluid index (AFI) of ‰¤ 5 cm or a single deep pocket (SDP) of Oligohydramnios
• Nonreassuring fetal monitoring Fetal monitoring The primary goals of antepartum testing and monitoring are to assess fetal well-being, identify treatable situations that may cause complications, and evaluate for chromosomal abnormalities. These tests are divided into screening tests (which include cell-free DNA testing, serum analyte testing, and nuchal translucency measurements), and diagnostic tests, which provide a definitive diagnosis of aneuploidy and include chorionic villus sampling (CVS) and amniocentesis. Antepartum Testing and Monitoring prior to the procedure
• A hyperextended fetal head
• Significant fetal or uterine anomalies
• Leads to fetal and maternal hemorrhage
• An immediate CD is required.
• If the version was successful, labor should be induced immediately.
• If the version was unsuccessful, the mother should undergo immediate CD.
• Cord prolapse: can occur with PROM PROM Prelabor rupture of membranes (PROM), previously known as premature rupture of membranes, refers to the rupture of the amniotic sac before the onset of labor. Prelabor rupture of membranes may occur in term or preterm pregnancies. Prelabor Rupture of Membranes and requires immediate/emergent CD.
• Common during the procedure, but typically resolves shortly after pressure on the abdomen is released.
• If distress persists, the mother should undergo an immediate CD.

Cesarean delivery Cesarean Delivery Cesarean delivery (CD) is the operative delivery of ≥ 1 infants through a surgical incision in the maternal abdomen and uterus. Cesarean deliveries may be indicated for a number of either maternal or fetal reasons, most commonly including fetal intolerance to labor, arrest of labor, a history of prior uterine surgery, fetal malpresentation, and placental abnormalities. Cesarean Delivery

• Scheduled at 39 weeks’ gestational age Gestational age The age of the conceptus, beginning from the time of fertilization. In clinical obstetrics, the gestational age is often estimated as the time from the last day of the last menstruation which is about 2 weeks before ovulation and fertilization. Pregnancy: Diagnosis, Physiology, and Care (WGA) if the infant is known to be in the breech presentation.
• Alternative option to attempting ECV
• Postpartum hemorrhage Postpartum hemorrhage Postpartum hemorrhage is one of the most common and deadly obstetric complications. Since 2017, postpartum hemorrhage has been defined as blood loss greater than 1,000 mL for both cesarean and vaginal deliveries, or excessive blood loss with signs of hemodynamic instability. Postpartum Hemorrhage
• Postpartum endomyometritis
• Maternal injury
• Longer recovery time postpartum
• Complications in future pregnancies (e.g., placenta previa Placenta Previa Abnormal placentation in which the placenta implants in the lower segment of the uterus (the zone of dilation) and may cover part or all of the opening of the cervix. It is often associated with serious antepartum bleeding and premature labor. Placental Abnormalities , placenta accreta Placenta Accreta Abnormal placentation in which all or parts of the placenta are attached directly to the myometrium due to a complete or partial absence of decidua. It is associated with postpartum hemorrhage because of the failure of placental separation. Placental Abnormalities , uterine rupture Uterine Rupture A complete separation or tear in the wall of the uterus with or without expulsion of the fetus. It may be due to injuries, multiple pregnancies, large fetus, previous scarring, or obstruction. Antepartum Hemorrhage )
• Maternal request (mother declines ECV attempt)
• ECV contraindicated
• ECV unsuccessful
• Fetal distress during labor

Management of transverse presentations

• As with breech presentations, mothers may be offered an attempt at ECV or a CD.
• Unlike breech presentations, vaginal transverse delivery is always contraindicated.
• Hofmeyr, G.J. (2021). Overview of breech presentation. In Barss, V.A. (Ed.), UpToDate. Retrieved July 14, 2021, from https://www.uptodate.com/contents/overview-of-breech-presentation  
• Hofmeyr, G.J. (2021). Delivery of the singleton fetus in breech presentation. In Barss, V.A. (Ed.), UpToDate. Retrieved July 14, 2021, from https://www.uptodate.com/contents/delivery-of-the-singleton-fetus-in-breech-presentation  
• Hofmeyr, G.J. (2021). External cephalic version. In Barss, V.A. (Ed.), UpToDate. Retrieved July 14, 2021, from https://www.uptodate.com/contents/external-cephalic-version  
• Julien, S., and Galerneau, F. (2021). Face and brow presentations in labor. In Barss, V.A., (Ed.), UpToDate. Retrieved July 14, 2021, from https://www.uptodate.com/contents/face-and-brow-presentations-in-labor  
• Strauss, R.A., Herrera, C.A. (2021). Transverse fetal lie. In Barss, V.A., (Ed.), UpToDate. Retrieved July 14, 2021, from https://www.uptodate.com/contents/transverse-fetal-lie  
• Barth, W.H. (2021). Compound fetal presentation. In Barss, V.A., (Ed.), UpToDate. Retrieved July 14, 2021, from https://www.uptodate.com/contents/compound-fetal-presentation  
• Cunningham, F. G., Leveno, K. J., et al. (2010). Williams Obstetrics, 23rd ed., pp. 374‒382. 

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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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vertex presentation

Medical Definition of vertex presentation

Dictionary entries near vertex presentation, cite this entry.

“Vertex presentation.” Merriam-Webster.com Medical Dictionary , Merriam-Webster, https://www.merriam-webster.com/medical/vertex%20presentation. Accessed 29 Apr. 2024.

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What the New Overtime Rule Means for Workers

One of the basic principles of the American workplace is that a hard day’s work deserves a fair day’s pay. Simply put, every worker’s time has value. A cornerstone of that promise is the  Fair Labor Standards Act ’s (FLSA) requirement that when most workers work more than 40 hours in a week, they get paid more. The  Department of Labor ’s new overtime regulation is restoring and extending this promise for millions more lower-paid salaried workers in the U.S.

Overtime protections have been a critical part of the FLSA since 1938 and were established to protect workers from exploitation and to benefit workers, their families and our communities. Strong overtime protections help build America’s middle class and ensure that workers are not overworked and underpaid.

Some workers are specifically exempt from the FLSA’s minimum wage and overtime protections, including bona fide executive, administrative or professional employees. This exemption, typically referred to as the “EAP” exemption, applies when: 

1. An employee is paid a salary,  

2. The salary is not less than a minimum salary threshold amount, and 

3. The employee primarily performs executive, administrative or professional duties.

While the department increased the minimum salary required for the EAP exemption from overtime pay every 5 to 9 years between 1938 and 1975, long periods between increases to the salary requirement after 1975 have caused an erosion of the real value of the salary threshold, lessening its effectiveness in helping to identify exempt EAP employees.

The department’s new overtime rule was developed based on almost 30 listening sessions across the country and the final rule was issued after reviewing over 33,000 written comments. We heard from a wide variety of members of the public who shared valuable insights to help us develop this Administration’s overtime rule, including from workers who told us: “I would love the opportunity to...be compensated for time worked beyond 40 hours, or alternately be given a raise,” and “I make around $40,000 a year and most week[s] work well over 40 hours (likely in the 45-50 range). This rule change would benefit me greatly and ensure that my time is paid for!” and “Please, I would love to be paid for the extra hours I work!”

The department’s final rule, which will go into effect on July 1, 2024, will increase the standard salary level that helps define and delimit which salaried workers are entitled to overtime pay protections under the FLSA. 

Starting July 1, most salaried workers who earn less than $844 per week will become eligible for overtime pay under the final rule. And on Jan. 1, 2025, most salaried workers who make less than $1,128 per week will become eligible for overtime pay. As these changes occur, job duties will continue to determine overtime exemption status for most salaried employees.

The rule will also increase the total annual compensation requirement for highly compensated employees (who are not entitled to overtime pay under the FLSA if certain requirements are met) from $107,432 per year to $132,964 per year on July 1, 2024, and then set it equal to $151,164 per year on Jan. 1, 2025.

Starting July 1, 2027, these earnings thresholds will be updated every three years so they keep pace with changes in worker salaries, ensuring that employers can adapt more easily because they’ll know when salary updates will happen and how they’ll be calculated.

The final rule will restore and extend the right to overtime pay to many salaried workers, including workers who historically were entitled to overtime pay under the FLSA because of their lower pay or the type of work they performed. 

We urge workers and employers to visit  our website to learn more about the final rule.

Jessica Looman is the administrator for the U.S. Department of Labor’s Wage and Hour Division. Follow the Wage and Hour Division on Twitter at  @WHD_DOL  and  LinkedIn .  Editor's note: This blog was edited to correct a typo (changing "administrator" to "administrative.")

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Fact Sheet on FTC’s Proposed Final Noncompete Rule

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The following outline provides a high-level overview of the FTC’s proposed final rule :

• Specifically, the final rule provides that it is an unfair method of competition—and therefore a violation of Section 5 of the FTC Act—for employers to enter into noncompetes with workers after the effective date.
• Fewer than 1% of workers are estimated to be senior executives under the final rule.
• Specifically, the final rule defines the term “senior executive” to refer to workers earning more than $151,164 annually who are in a “policy-making position.”
• Reduced health care costs: $74-$194 billion in reduced spending on physician services over the next decade.
• New business formation: 2.7% increase in the rate of new firm formation, resulting in over 8,500 additional new businesses created each year.
• This reflects an estimated increase of about 3,000 to 5,000 new patents in the first year noncompetes are banned, rising to about 30,000-53,000 in the tenth year.
• This represents an estimated increase of 11-19% annually over a ten-year period.
• The average worker’s earnings will rise an estimated extra $524 per year. 

The Federal Trade Commission develops policy initiatives on issues that affect competition, consumers, and the U.S. economy. The FTC will never demand money, make threats, tell you to transfer money, or promise you a prize. Follow the  FTC on social media , read  consumer alerts  and the  business blog , and  sign up to get the latest FTC news and alerts .