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

, MD, Children's Hospital of Philadelphia

Variations in Fetal Position and Presentation

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

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

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

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

Head first (called vertex or cephalic presentation)

Facing backward (occiput anterior position)

Spine parallel to mother's spine (longitudinal lie)

Neck bent forward with chin tucked

Arms folded across the chest

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

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

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

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

There is more than one fetus (multiple gestation).

Position and Presentation of the Fetus

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

Occiput posterior position

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

Breech presentation

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

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

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

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

Labor starts too soon (preterm labor).

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

Other presentations

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

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

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

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

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

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

Fetal presentation and position

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

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

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

Medical illustrations by Jonathan Dimes

Head down, facing down (anterior position)

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

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

Head down, facing up (posterior position)

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

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

Frank breech

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

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

Complete breech

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

Incomplete breech

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

Single footling breech

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

Double footling breech

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

Transverse lie

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

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

Oblique lie

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

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

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What to know if your baby is breech

What's a sunny-side up baby?

What happens to your baby right after birth

Perineal massage

BabyCenter's editorial team is committed to providing the most helpful and trustworthy pregnancy and parenting information in the world. When creating and updating content, we rely on credible sources: respected health organizations, professional groups of doctors and other experts, and published studies in peer-reviewed journals. We believe you should always know the source of the information you're seeing. Learn more about our editorial and medical review policies .

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

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

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

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

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• Pregnancy week by week
• Fetal presentation before birth

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

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

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

Head down, face down

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

Head down, face up

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

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

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

Frank breech

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

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

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

Complete and incomplete breech

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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Cephalic presentation

October 14, 2016

A cephalic presentation or head presentation or head-first presentation is a situation at childbirth where the fetus is in a longitudinal lie and the head enters the pelvis first; the most common form of cephalic presentation is the vertex presentation where the occiput is the leading part (the part that first enters the birth canal). All other presentations are abnormal (malpresentations) which are either more difficult to deliver or not deliverable by natural means.

The movement of the fetus to cephalic presentation is called head engagement. It occurs in the third trimester. In head engagement, the fetal head descends into the pelvic cavity so that only a small part (or none) of it can be felt abdominally. The perineum and cervix are further flattened and the head may be felt vaginally. Head engagement is known colloquially as the baby drop, and in natural medicine as the lightening because of the release of pressure on the upper abdomen and renewed ease in breathing. However, it severely reduces bladder capacity, increases pressure on the pelvic floor and the rectum, and the mother may experience the perpetual sensation that the fetus will “fall out” at any moment.

The vertex is the area of the vault bounded anteriorly by the anterior fontanelle and the coronal suture, posteriorly by the posterior fontanelle and the lambdoid suture and laterally by 2 lines passing through the parietal eminences.

In the vertex presentation the occiput typically is anterior and thus in an optimal position to negotiate the pelvic curve by extending the head. In an occiput posterior position, labor becomes prolonged and more operative interventions are deemed necessary. The prevalence of the persistent occiput posterior is given as 4.7 %

The vertex presentations are further classified according to the position of the occiput, it being right, left, or transverse, and anterior or posterior:

Left Occipito-Anterior (LOA), Left Occipito-Posterior (LOP), Left Occipito-Transverse (LOT); Right Occipito-Anterior (ROA), Right Occipito-Posterior (ROP), Right Occipito-Transverse (ROT);

By Mikael Häggström – Own work, Public Domain  

Cephalic presentation. (2016, September 17). In Wikipedia, The Free Encyclopedia . Retrieved 05:18, September 17, 2016, from https://en.wikipedia.org/w/index.php?title=Cephalic_presentation&oldid=739815165

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Your baby in the birth canal

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

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

Information

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

FETAL STATION

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

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

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

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

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

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

FETAL ATTITUDE

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

The normal fetal attitude is commonly called the fetal position.

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

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

DELIVERY PRESENTATION

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

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

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

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

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

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

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

CARDINAL MOVEMENTS OF LABOR

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

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

Internal Rotation

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

External Rotation

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

Alternative Names

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

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

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

Review Date 11/10/2022

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

Related MedlinePlus Health Topics

• Childbirth Problems

Which Way Is Up? What Your Baby’s Position Means For Your Delivery

by Physicians & Midwives | Feb 11, 2022 | Pregnancy

“Will I be able to have a vaginal delivery?”, “Will labor pains be more in my pelvis or back?”, and “How long will labor and delivery last?” are all questions that have probably entered your head at some point. The answers to these questions, in large part, depend on the position of your baby within your uterus at the time you go into labor. Medical professionals call this the fetal presentation and position. Let’s break down different fetal presentations and what your baby’s position could mean for your delivery.

Cephalic presentation

Almost all (95-97%) babies are delivered by cephalic presentation, where they are head-down with legs and feet at the top of the uterus. Most babies move into the head-down position by the third trimester. Cephalic presentation is further broken down by the position of the head; in the vast majority of cephalic deliveries, the crown or top of the head (called the vertex), enters the birth canal first and is the first part of the baby to be delivered. This is what we mean when we say a baby is “crowning”.

In most cases of vertex presentation, the back of the baby’s head (called the occiput) is toward the front (anterior) of the mother’s pelvis. This presentation is called occiput anterior and is considered the best position for a vaginal delivery. This position is considered best because this position typically leads to the easiest navigation of the baby through the birth canal.

Around 5% of babies are delivered in the occiput posterior position, where the back of the baby’s head is toward the mother’s backbone and tailbone. This is popularly believed to be the cause of painful “back labor”, although the scientific support for this is somewhat lacking. What is known is that the occiput posterior presentation can significantly prolong labor, and is three times more likely than occiput anterior presentation to result in cesarean section. This comes down to less ease of passage through the birth canal. Occiput posterior presentation is more common in older and first-time mothers, as well as with larger or overdue babies. Surfing the internet will provide you with many different exercises which claim to prevent occiput posterior presentation, but none of these have been scientifically proven to be of benefit.

Rarely (around 1 in every 800 births), the baby will present face-first instead of with the top of the head. Around 70% of these babies can be delivered vaginally, although the labor may be mildly prolonged. The remainder tend to be delivered by cesarean section either because the labor is not progressing or because the doctor or midwife is concerned about the baby’s heart rate. Around 5% of babies are delivered in the occiput posterior position, where the back of the baby’s head is toward the mother’s backbone and tailbone. This is popularly believed to be the cause of painful “back labor”, although the scientific support for this is somewhat lacking. What is known is that the occiput posterior presentation can significantly prolong labor, and is three times more likely than occiput anterior presentation to result in cesarean section. This comes down to less ease of passage through the birth canal. Occiput posterior presentation is more common in older and first-time mothers, as well as with larger or overdue babies. Surfing the internet will provide you with many different exercises which claim to prevent occiput posterior presentation, but none of these have been scientifically proven to be of benefit.

Breech presentation

Shoulder presentation.

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Malposition and cephalic malpresentations

Chapter Forty-Three. Malposition and cephalic malpresentations CHAPTER CONTENTS Introduction 581 Occipitoposterior position of the vertex 581 Causes 581 Risks 582 Diagnosis in pregnancy 582 Diagnosis in labour 583 The first stage of labour 583 The second stage of labour 585 Face presentation 587 Causes 587 Risks 587 Diagnosis 587 Progress and outcomes of labour 588 Brow presentation 589 Diagnosis 589 Management 589 Shoulder presentation 589 Causes 589 Diagnosis 589 Management 590 Compound presentation 590 Introduction If the vertex is the denominator in a cephalic presentation, the term malpresentation is not used. The correct word to use for occipitoposterior position of the vertex is malposition . True cephalic malpresentations are face and brow. Also included is a shoulder presentation resulting from oblique or transverse lie; this is a rare but dangerous event. Each of these situations may affect the length and outcome of the labour and require vigilance to prevent maternal and fetal morbidity and, rarely, mortality. The more common occipitoposterior position will be discussed first as it may lead to secondary brow or face presentation. Occipitoposterior position of the vertex In occipitoposterior position of the vertex, the occiput occupies one of the two posterior quadrants of the mother’s pelvis and the sinciput points towards the opposite anterior quadrant ( Fig. 43.1 ). Malposition is common and affects about 10% of all labours. The outcome of such labours is generally normal with rotation of the occiput to the anterior and normal vertex delivery. However, there may be prolonged labour and mechanical difficulties associated with the delivery. Figure 43.1 Right and left occipitoposterior positions. (From Henderson C, Macdonald S 2004, with kind permission of Elsevier.) Causes There is no single satisfactory cause for occipitoposterior position. However, if the forepelvis is small, as found in android and anthropoid pelves, the head may take up a posterior position. Other possible causes include a pendulous abdomen, a flat sacrum or an anterior placenta ( Lewis 2004 ). Attitude Instead of the normal well-flexed attitude with the limbs and head flexed on the trunk and the rounded back pointing towards the mother’s soft abdominal wall, the fetal spine faces the forward curve of the maternal lumbar spine and good flexion is not possible. The fetal spine is straightened, the head is held in a deflexed position known as the ‘military position’ and the anterior fontanelle is found directly over the internal os. The term ‘bregmatic presentation’ is sometimes used ( Lewis 2004 ). This position of the head brings larger diameters into relationship with the pelvic brim and engagement of the head may not occur. Risks • Obstructed labour if either deep transverse arrest or brow presentation result. • Maternal perineal trauma such as a third-degree tear and bruising. • Cord prolapse if there is early spontaneous rupture of the membranes and ill-fitting presenting part. • Neonatal cerebral haemorrhage due to upward moulding of the fetal skull. The falx cerebri may be pulled away from the tentorium cerebelli, resulting in a tear of the great vein of Galen. • Chronic fetal hypoxia, if present, results in venous distension, which increases the likelihood of haemorrhage. Diagnosis in pregnancy Occipitoposterior position is the most common cause of a non-engaged head in late pregnancy in primigravidae. The woman may complain that the baby has too many hands and feet and that she has to pass urine more frequently in the absence of infection ( El Halta 1996 ). Abdominal examination will confirm the diagnosis: • On inspection : the abdomen appears flattened. There may be a saucer-shaped depression below the umbilicus between the fetal head and limbs ( Fig. 43.2A ). Figure 43.2 (A) Abdominal contour with occipitoposterior position, showing depression at umbilicus. (B) Rounded abdominal contour with occipitoanterior position. (From Henderson C, Macdonald S 2004, with kind permission of Elsevier.) • On palpation : the fetal head is high and deflexed. It may feel large if the occiput is more lateral but small if the occiput is quite posterior and the bitemporal diameter is palpated. Fetal limbs may be felt on both sides of the midline of the uterus and the fetal back may be felt out in the flank ( Fig. 43.3 ). Figure 43.3 In occipitoposterior positions the anterior shoulder is well out from the midline and fetal limbs are readily palpable. This may cause a mistaken diagnosis of multiple pregnancy. (From Beischer N A, Mackay E V 1986 Obstetrics and the Newborn. Baillière Tindall, London, with kind permission of Elsevier.) • On auscultation : the fetal heart may be heard at or just above the umbilicus or out in one flank. Diagnosis in labour Abdominal examination, as described above, will indicate the presence of an occipitoposterior position although the head may be flexed and become engaged. On vaginal examination, palpation of the anterior fontanelle is a diagnostic aid in determining occipitoposterior position ( ALSO 2005 ). If the head is reasonably well flexed, the anterior fontanelle will be felt anteriorly and it may be possible to feel the posterior fontanelle. When the head is deflexed, the anterior fontanelle is almost central and easy to feel by its shape and size ( Fig. 43.4B ). Figure 43.4 Position of the anterior and posterior fontanelles. (A) Occipitoanterior. (B) Occipitoposterior. (From Henderson C, Macdonald S 2004, with kind permission of Elsevier.) The first stage of labour Fetal malposition of occipitoposterior is associated with more painful, prolonged and obstructed labour and a difficult delivery ( Hunter et al 2007 ). The course of labour partly depends on the degree of descent and flexion that takes place ( Fig. 43.5 ). This in turn is influenced by the strength of uterine contractions. If the head flexes, it is likely that labour will proceed normally. The engaging diameter is the suboccipitofrontal (10 cm). When the occiput reaches the pelvic floor and rotates ths of a circle, the baby is born with the occiput anterior. Figure 43.5 Outcome of an occipitoposterior position. The head enters the pelvis with the occiput posteriorly. The outcome can be A, B or C. (From Henderson C, Macdonald S 2004, with kind permission of Elsevier.) If the head remains deflexed, problems may arise. The engaging diameter is the occipitofrontal (11.5 cm). The head may be non-engaged at the commencement of labour and early rupture of the membranes may occur. If the presenting part is high and not well applied to the cervix, there is a risk of cord prolapse. Labour is prolonged because of poor stimulation of the cervix and dilation is slow and uneven. Contractions may be excessive but uncoordinated and painful and the woman experiences severe backache. Encouraging the mother to take up a knee–chest position for 45 min may help rotation of the vertex to an anterior position ( El Halta 1996 ). Augmentation of labour may be necessary (see Chapter 41 ). Care must be taken to prevent maternal loss of confidence, ketosis and dehydration and fetal distress. There may be difficulty in micturition with retention of urine and the woman needs encouragement to empty her bladder frequently. Catheterisation may be necessary if the woman is unable to pass urine. The role of maternal position Hunter et al (2007) discuss the benefits of upright and leaning-forward postures in order to encourage the fetal head to engage in the optimal occipitoanterior position. Avoidance of a reclining position with the knees higher than the hips will reduce the incidence of occipitoposterior position of the fetal head at the commencement of labour ( Sutton 2001 ). Taking up an all-fours posture may reduce the pressure of the fetus on the maternal spine and help to reduce backache. It may also aid rotation of the fetus to an occipitoanterior position ( Simkin & Ancheta 2005 ). It has been suggested that in the antenatal period if a woman adopts a hands-and-knees posture leaning forward then this might promote a favourable position of the baby ( Hunter et al 2007 ). Three trials (2794 women) were included in a systematic review ( Hunter et al 2007 ) to explore this issue. Two trials were focused on the antenatal period. In one trial (100 women), four different postures (four groups of 20 women) were combined for comparison with the control group of 20 women. Findings were that in the lateral or posterior position the presenting part of the fetus was less likely to persist following 10 min in the hands-and-knees position compared to a sitting position. In a second trial (2547 women), advice to assume the hands-and-knees posture for 10 min twice daily in the last weeks of pregnancy had no effect on the baby’s position at delivery or on any of the other pregnancy outcomes. Simkin & Ancheta (2005) detail the advantages of ambulation and forward-leaning positions in labour. Freedom to move around in the first stage of labour and the maintenance of an upright position such as can be achieved by sitting astride a chair and leaning on its back have been shown to be beneficial to women with an occipitoposterior presentation. Descent of the fetal head is encouraged and good uterine contractions should follow. Progress is more likely to be normal, culminating in long internal rotation of the occiput (see below). In the second stage of labour, the squatting position increases the anteroposterior diameter of the outlet and may aid rotation, descent and delivery. The third trial in the systematic review of Hunter et al studied the use of hands-and-knees position in labour. The sample comprised 147 labouring women at 37 or more weeks’ gestation, where the fetal occipitoposterior position was confirmed by ultrasound. Randomisation occurred: 70 women (intervention group) assumed hands-and-knees positioning for a period of at least 30 min compared to 77 women (control group) who did not assume hands-and-knees positioning in labour. There was no statistical significance in the reduction of occipitoposterior or transverse positions at delivery and operative deliveries. However, there was a significant reduction in back pain. The authors conclude from the evidence in the systematic review ( Hunter et al 2007 ) that adopting these positions as a recommended intervention could not be endorsed. However, they stated that if the women find these positions comfortable then they should adopt them and especially in labour where maternal backache is reduced. Relieving backache To relieve the backache, many women find the kneeling position beneficial. This position may also aid rotation of the head to an occipitoanterior position. Massaging the woman’s back in the lumbosacral region may also help to relieve the backache and a warm bath has been found to be helpful. Epidural analgesia is the most effective method of relieving the pain. In the second stage of labour, perineal trauma is minimised by an upright position ( Aasheim et al 2007 ). A difficult problem for the woman in the late first stage of labour is feeling a strong urge to push before full cervical dilatation. Pushing presses the fetal head against the cervix and oedema may occur, thus lengthening the transitional stage of labour. Simkin & Ancheta (2005) suggest that the adoption of the kneeling position with the head resting on the forearms may lessen the pressure on the cervix. The second stage of labour The five main possible outcomes of an occipitoposterior position are: 1. Long internal rotation of the occiput and delivery as an occipitoanterior. 2. Deep transverse arrest of the head.

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Intrapartum Ultrasound Assessment of Fetal Spine Position

Salvatore gizzo.

1 Department of Woman and Child Health, University of Padua, Via Giustiniani 3, 35128 Padova, Italy

2 Dipartimento di Salute della Donna e del Bambino, U.O.C. di Ginecologia e Ostetricia, Via Giustiniani 3, 35128 Padova, Italy

Alessandra Andrisani

Marco noventa, giorgia burul, stefania di gangi, emanuele ancona, donato d'antona, giovanni battista nardelli, guido ambrosini.

We investigated the role of foetal spine position in the first and second labour stages to determine the probability of OPP detection at birth and the related obstetrical implications. We conducted an observational-longitudinal cohort study on uncomplicated cephalic single foetus pregnant women at term. We evaluated the accuracy of ultrasound in predicting occiput position at birth, influence of fetal spine in occiput position during labour, labour trend, analgesia request, type of delivery, and indication to CS. The accuracy of the foetal spinal position to predict the occiput position at birth was high at the first labour stage. At the second labour stage, CS (40.3%) and operative vaginal deliveries (23.9%) occurred more frequently in OPP than in occiput anterior position (7% and 15.2%, resp.), especially in cases of the posterior spine. In concordant posterior positions labour length was greater than other ones, and analgesia request rate was 64.1% versus 14.7% for all the others. The assessment of spinal position could be useful in obstetrical management and counselling, both before and during labour. The detection of spinal position, more than OPP, is predictive of successful delivery. In concordant posterior positions, the labour length, analgesia request, operative delivery, and caesarean section rate are higher than in the other combination.

1. Introduction

The foetal head typically engages in the transverse diameter late in the third trimester and usually rotates to an occipitoanterior (OAP) or occipitoposterior (OPP) position. OPP occurs in 15–20% of women before labour at term [ 1 ].

Approximately 90–95% of these foetuses rotate during labour once the head reaches the pelvic floor [ 1 , 2 ]. Thus, most of the OPP deliveries seem to arise as a consequence of a malrotation from the initial OAP or transverse position (OTP), rather than a persistent OPP. OPP incidence at birth ranges between 1 and 5% [ 2 , 3 ].

Intrapartum ultrasound may improve the detection of fetal head position [ 4 ]. Although the identification of OPP before or during labour is not predictive of the same position at delivery, its early detection argues for a greater monitoring of the labour evolution [ 4 , 5 ].

Blasi et al. [ 6 ] showed that the diagnostic sonographic accuracy of the foetal occiput position assessment at the second stage of labour had a sensitivity of 100%, specificity of 78%, positive predictive value (PPV) of 26%, and negative predictive value (NPV) of 100% to predict the same position at birth. Considering the foetal spinal position, ultrasound showed a sensitivity of 100%, specificity of 98%, PPV of 85%, and NPV of 100% [ 6 ].

Peregrine et al. [ 1 ] demonstrated that the foetal spine and occiput were often not concordant, but the posterior positioned spine was detected in nearly 14.5% of deliveries frequently associated with OPP [ 1 ]. Recent literature confirms that OPP represents an obstetric challenge because it is associated with an increased maternal foetal and neonatal morbidity, and its management is still debated [ 6 ].

In obstetrical practice, pregnant women with OPP foetuses present prolonged second stages of labour, higher rates of episiotomy, and severe perineal lacerations, mainly owing to the higher rates of instrumental delivery and increased risks of Caesarean section (CS) by nearly 4-fold [ 7 ].

The first aim of this study was to investigate the role of foetal spinal position in the first and second stages of labour in determining persistent OPP at birth. The second aim of the study was to investigate the implications of persistent OPP during labour in terms of the mode of delivery, length of labour, and analgesia request rate.

2. Patients and Methods

An observational study was conducted on pregnant women at term who delivered in the Gynaecological and Obstetric Clinic, Department of Woman and Child's Health of Padua University Hospital, between December 2011 and August 2013.

All patients were properly informed about the procedure and consented to the use of their data for this study by written consent, respecting their privacy (Italian Law 675/96).

After consulting the local ethical committee, our study was defined as exempt by the Institutional Review Board (IRB). Approval from the local IRB for the health sciences is not required for observational studies because the clinical management and/or surgical approach were not modified by the investigators. All patient data were made anonymous.

All women were consecutively enrolled by the researchers and carried out the ultrasound assessment at the first stage of labour, with or without the spontaneous rupture of membranes and a Bishop Score ≤7.

Inclusion criteria were as follows: age 18–40 years old, uncomplicated pregnancy, single foetus in cephalic presentation, normal foetal heart rate pattern status, and parity ≤3. We included also patients with history of third-trimester isolated oligohydramnios [ 8 ].

Exclusion criteria were as follows: history of uterine malformation, previous uterine surgery, pregnancies obtained by assisted reproductive techniques, suspicion of foetal malformation, intrauterine growth restriction, estimated foetal weight ≥4500 gr (calculated using ultrasound measurements by the Hadlock formula) [ 9 ], maternal fever of more than 38°C at admission, and incomplete obstetrical data about the trends of labour.

The stages of labour were established by the members of midwifery staff assisting the patients. The beginning of labour was defined by regular uterine contractions and changes in the cervical dilatation of more than 2 cm, according to the defined criteria [ 10 ]; the second stage was defined by attaining a full dilatation of the cervix.

For all of the patients, data were collected on the following: maternal age, gestational age, parity, type of labour (spontaneous or induced), length of the first and second stages of labour (in minutes), maternal request of epidural analgesia, type of delivery (spontaneous, operative, or Caesarean section), indications for caesarean section, neonatal weight (in grams), and length (in centimetres).

The ultrasound examination was performed by one of the researchers (Giorgia Burul) who had previously been trained for six months in the use of intrapartum ultrasounds. The researcher who performed intrapartum ultrasound examination was blinded to clinical examinations performed by midwifery or clinician during labour. The transabdominal (TA) scan was performed in the maternal supine position with a 3.5 MHz convex probe AB2-7-RS (Voluson e6 compact-GE Healthcare, GE Medical Systems Ltd, Diagnostic Imaging/Ultrasound/Life Care Solutions, 71 Great North Road, Hatfield, Hertfordshire) . As previously described [ 11 – 14 ], the landmarks depicting fetal occipital position (anterior, transverse, or posterior) were the fetal orbits for occiput posterior position, the midline cerebral echo for occiput transverse position, and cerebellum or occiput for occiput anterior position. The position of the foetal spine was determined by obtaining a transverse section of the foetal chest at the four-chamber view of the heart.

The positions of the spinal column and occiput were defined, as previously reported by Blasi et al. [ 6 ] and Akmal et al. [ 12 ], with the ultrasound findings for each foetus being reported on a clock-like chart divided into 12 sections, each representing 30°. The anterior position was determined if the occiput or spine was anterior (9.30–2.29), with other positions described as transverse right (8.30–9.29), transverse left (2.30–3.29), or posterior (3.30–8.29) [ 6 ]. At delivery, all foetal occiput positions were also recorded.

Occiput position and spinal column position were detected by TA ultrasound evaluation at the beginning of the labour (3 cm of cervical dilation) and at the second stage of labour (after the patient was diagnosed to be fully dilated); at birth, the occiput position was detected by clinical evaluation. When CS was performed before the complete cervical dilation, we documented occiput and spinal positions before the CS.

Midwifery and clinicians were blinded to ultrasound reports and to the aim of the study. They assisted the parturient according to our delivery room protocols and we collected information about labour from the final delivery report. Statistical analysis was performed by SPSS (IBM company, Chicago, IL, USA) software for Windows version 19, using parametric and nonparametric tests where appropriate. We performed the Kolmogorov-Smirnov test for the normality of the distribution. Continuous data were tested with t -tests, performing the ANOVA test when necessary, and categorical variables were tested with the χ 2 test or Fisher's exact test, where appropriate. The results obtained from the data collection were expressed in absolute numbers and percentages for discrete variables and in means ± standard deviations for continuous variables. Statistical significance was defined as P < 0.05.

Among all of the pregnant women admitted to the delivery room of the Obstetric and Gynaecological Unit of Padua during the chosen time period, 256 patients were eligible for inclusion into the study.

Data about maternal age, gestational age, parity, type of labour, length of the first and the second stages of labour, maternal request of epidural analgesia, type of delivery, neonatal birth weight, neonatal length, and indications for Caesarean section were reported in Table 1 .

Data about general maternal foetal features and labour characteristics.

*Data about only patients who delivered through the vaginal route.

Data about the occiput and spinal positions detected at the beginning and second stages of the labour and the occiput position at delivery were reported in Tables ​ Tables2 2 and ​ and3 3 .

Data about the occiput and spinal positions during the first and second stages of labour (for all patients) and at delivery (only in vaginal deliveries).

§ Of these, 71 cases changed position, 68 cases shifted to the occiput anterior position, and three cases shifted to the transverse position.

# Among the 47 cases of posterior spinal position, 42 (89%) showed a concordant occiput posterior position, whereas the remaining five cases showed a nonconcordant occiput position. The results in all cases were in the transverse position.

∗Of these, 62 already belonged to the occiput posterior position at the first stage of labour, and five changed into the occiput posterior position from the transverse position at first stage.

∗∗All of the 41 posterior spinal positions detected at the second stage of labour were in the same position at the first stage of labour. Only six posterior spinal positions at the first stage of labour changed into the other position, four cases changed to the anterior spinal position, and two cases changed to the transverse position.

Detailed data about the posterior position (both occiput and spine) trends in the first and second stages of labour in terms of the concordant position and mode of delivery.

The diagnostic ultrasound accuracy of foetal occiput and spinal position in predicting the occiput position at birth was calculated only in the 210 patients who delivered vaginally.

The sensitivity of the OPP in predicting the same position at birth was 93.7% in the first stage of labour and 87.5% in the second stage of labour, with a specificity of 55.2% and 86.5%, respectively. The positive likelihood ratio was 2.09 in the first stage of labour and 6.48 in the second stage of labour, and the negative likelihood ratios were 0.11 and 0.14, respectively ( Table 4 ).

Estimation of the sensitivity, specificity, positive and negative predictive values (PPV and NPV), positive and negative likelihood ratios (LR+ and LR−), and their 95% CIs for the occiput and spinal position in the first and second stages of labour in predicting occiput posterior position at birth.

*95% CI estimated by the Wilson method and by the binomial exact test, when necessary.

The sensitivity of the posterior spinal position in predicting the same position at birth was 100% in the first stage of labour and 93.7% in the second stage of labour, and the specificities were 80% and 100%, respectively. The positive likelihood ratio was 41.7 in the first stage of labour and tended toward infinity at the second stage of labour, and the negative likelihood ratios were 0 and 0.06, respectively ( Table 4 ).

Data about the type of delivery showed that 168 patients (65.6%) delivered vaginally without interventions, 42 (16.4%) delivered vaginally requiring interventions (operative delivery), and 46 (18%) delivered by CS.

From the correlations between occiput position at the second stage of labour and the resultant type of delivery, CS occurred in 40.3% of patients with OPP versus 38.9% of OTP and 7% of OAP patients ( P < 0.05). On the contrary, no significant differences were detected between occiput position at the first stage of labour and the CS rate, despite OPP's showing a higher CS probability compared to the other positions.

Considering spinal position at second stage of labour, CS occurred in 63.4% of the posterior positioned, 15.4% of the transverse positioned, and 8% of the anterior positioned deliveries ( P < 0.01).

In contrast to OPP, the CS rate showed a significant difference in relation to the spinal position at the first stage, with a rate of 57.4% when the spine was in the posterior position, 9.4% in the transverse position, and 8.2% in the anterior position ( P < 0.01).

Operative vaginal delivery occurred in 23.9% of OPP detected at the second stage of labour versus 15.2% in OAP and none in OTP ( P > 0.05). At the first stage of labour, no significant differences were detected among all of the occiput positions.

Regarding the spinal position detected at the second stage of labour, operative vaginal delivery occurred in 26.8% of the posterior positioned, versus 15.3% of the anterior positioned and 10.3% of the transverse positioned, deliveries ( P < 0.01).

Regarding the spinal position detected at the second stage of labour, operative vaginal delivery occurred in 29.8% of patients with posterior spinal positions, in 16.3% with anterior positions, and in 12.5% with transverse positions ( P < 0.01).

Data on the indications for CS and spinal position showed that all cases of dystocia (i.e., arrest of descent after two hours of active pushing) (13 patients) occurred when the spine was posterior, whereas only 39.4% (13 over 33 patients) of nonreassuring foetal hearts occurred in the same spinal position.

Data on patients who delivered vaginally (210 patients) showed that the length of the first stage of labour was 255.9 ± 119.6 minutes in OAP at birth, versus 439.7 ± 120.4 in OPP at birth ( P < 0.001). Similarly, the length of the second stage of labour and the total length of labour in OPP at birth were significantly longer than OAP at birth: 98.13 ± 40.5 versus 56.4 ± 30.2 minutes and 537.8 ± 146.9 versus 312.2 ± 139.1 minutes, respectively ( P < 0.01).

Among all patients, only 57 (23.3%) required epidural analgesia; in cases of concordant posterior position (occiput and spine) already at the first stage of labour, the rate of analgesia request was 64.1% versus 14.7% for all other combinations ( P < 0.001).

An interesting datum was that, among the 16 patients (15 with posterior spine) who delivered vaginally a newborn presenting OPP at birth, 93.7% received epidural analgesia during labour; on the contrary, the remaining 26 posterior spinal positions (detected at the second stage of labour) who delivered by CS, 4 received analgesia in only 11.5% of cases ( P < 0.001).

We provided to report data about fetal occiput and spine position at different stage of labour in the flow diagram ( Figure 1 ).

Synthetic flow diagram about fetal occiput and spine position at recruitment, during labour and at delivery (according to type of delivery). (i) OPP: occiput posterior position, (ii) OAP: occiput anterior position, (iii) OPT: occiput transverse position, (iv) posterior spine: foetal spinal column in posterior position, (v) ant./trasv. spine: foetal spinal column in anterior or transverse position (percentages are expressed each related to the proper cluster of population).

4. Discussion and Conclusion

4.1. main findings.

The foetal OPP during labour is associated with some unfavourable events, such as prolonged labour, need for assisted vaginal delivery, increased CS rate, and analgesia request rate [ 4 , 6 ].

Although the OPP foetus usually rotates to OAP, this often occurs after many hours and efforts to address a painful, exhausting, and nonprogressing labour. The mother is at added risk for severe back pain, fatigue, and discouragement and is in greater need for emotional support. The new-born is at greater risk for a five-minute Apgar score <7, acidic cord blood gas concentrations, meconium-stained amniotic fluid, admission to neonatal intensive care, and longer hospitalization [ 15 ]. Thus, OPP poses clinical challenges in intrapartum care prevention, diagnosis, correction, supportive care, labour management, and delivery.

Currently, ultrasound evaluation at term represents the most accurate, easy, and reproducible tool for assessing both foetal position and pelvic-perineal findings [ 6 , 15 , 16 ]. The improvement of the ultrasound investigation during labour has led to the ability to distinguish patients whose pregnancies will result in spontaneous vaginal deliveries from those who will require operative vaginal delivery or CS for progression failure [ 13 , 17 , 18 ].

In women undergoing the induction of labour, preinduction sonographic determination of the occipital position, in addition to cervical length, is superior to the Bishop score in the prediction of induction outcome [ 19 , 20 ]. Moreover, the sonographic detection of foetal head position is more accurate than vaginal examination both in the first and in the second stages of labour, particularly in OPP [ 21 – 23 ]. Despite these advantages, in the delivery room, ultrasound support still plays a secondary role with respect to clinical evaluation [ 1 ].

4.2. Strengths

Our strength points are the reported data about the different intrapartum outcomes (in homogeneous population) in relation to the spine position and the possible options that an early ultrasound detection of malposition could offer to women (more appropriate counseling, higher probability to benefit from fetal head manual rotation, and better management of labour and pain).

When OPP occurs, the assessment of the spinal position could be useful during the obstetrical decision-making process and the counselling of pregnant women before induction, or at the first stage of labour, especially when there are no indications for CS but poor chances of vaginal delivery.

4.3. Limitations

Our study had some limitations, due to the small sample size of the posterior spine and OPP cases and the performance of the ultrasounds by a single operator, even if the latter situation was necessary to eliminate interobserver bias. Another possible bias is linked to data about CS rate since in our unit (University Hospital) there is a high number of young resident gynecologists who resulted not skilled enough in performing intrapartum digital or manual rotation of the OPP in order to increase spontaneous deliveries and reduce CS and instrumental deliveries.

In our knowledge this study, differently from Blasi et al. [ 6 ], who focused only on intrapartum ultrasound diagnostic accuracy in predicting fetal spine and occiput position at different stages of labour, firstly investigated also the clinical impact of spine position in influencing the OPP persistence.

4.4. Interpretation

The importance of promoting intrapartum ultrasound examination is related to its high accuracy in predicting vaginal delivery and in facilitating the development of a decision-making strategy during labour [ 13 ]. According to this evidence, our data report that OPP at the second stage of labour is highly predictive of operative vaginal delivery or CS. Our study, according to Blasi et al. [ 6 ] and Peregrine et al. [ 1 ], reports that the concomitance between spine and occiput in the posterior position is more predictive than occiput alone in defining occiput position at birth. The posterior concomitance (occiput and spine), still in the first stage of labour, reveals a high accuracy in defining occiput position at birth and in predicting the labour trend.

Both the sensitivity and specificity of the spinal position are high in predicting the length of the labour and mode of delivery. The length of the labour, especially in the first stage, is increased in posterior spine when compared with the other positions. A spinal position different from the anterior position increases the risk of operative delivery and CS, even in the first labour stage, since, in our study, all cases of dystocia requiring CS occurred when the spine was posterior.

Many authors [ 3 , 12 , 24 , 25 ] have tried to explain the exact mechanism that leads to an OPP at birth. However, the results conflict with each other. In fact the correct sonographic method (abdominal or perineal), the timing of the ultrasound study (the first or the second stage of labour), and the use of the parameters for foetal head position assessment are still controversial.

First, Blasi et al. [ 6 ] showed the importance of foetal spinal position in the intrapartum ultrasound assessment of the foetal position during the second stage of labour in predicting OPP at birth. They found higher OPP prevalence during the first and second stages of labour than expected. All OPP cases at delivery had the same position on ultrasound evaluation during the second stage of labour, in particular when they had a concordant spinal position. The authors [ 6 ] concluded that the concordant posterior position during the second stage of labour could be a useful indicator for predicting OPP at delivery.

In our sample, despite the fact that the concordant posterior position implies CS in 63.4% of cases, vaginal delivery was not impossible, even if 26.8% of cases required an intervention (increasing the risk of vaginal delivery complications) [ 26 ]. Our data show that the performance of epidural analgesia could play a beneficial role in promoting vaginal delivery when the occiput and spine are posterior, most likely facilitating the foetal pelvic progression and reducing, in this cohort, the rate of dystocia.

This concept may be based on the assumption that epidural analgesia induces pain relief and pelvic muscles relaxation, so it would reduce the resistance facilitating the foetal engagement to the maternal pelvis. The role of the concordant posterior position in increasing maternal pain is demonstrated by the high rate of requested analgesia. By the first stage of labour, 64.1% of deliveries in the posterior position versus 14.7% of all other combinations had requested analgesia.

According to our hypothesis, Lieberman et al. [ 27 ] reported that the OPP persisted at vaginal delivery in 12.9% of the epidural group versus 3.3% of the nonepidural group. However, our study, similarly to all the others reported in Literature, may be affected by the bias linked to a reduced maternal activity due to epidural analgesia administration. This could have a negative influence on the possible intrapartum fetal head rotation, sometimes facilitated by maternal mobilization during labour [ 15 ].

The increased rate in OPP occurrence among pregnant women receiving epidural analgesia may represent a mechanism by which epidural analgesia can be considered a risk factor for operative delivery and CS.

The confirmed beneficial effects of epidural analgesia [ 28 ] allow its administration within the OPP population, increasing the chances of vaginal delivery and reducing the intrapartum CS rate and its related complications [ 29 , 30 ].

5. Conclusion

The assessment of the spinal position can be useful in the second stage of labour because it may help obstetricians to manage borderline intrapartum conditions, such as nonreassuring foetal heart rates, early signs of foetal distress, and maternal hyperpyrexia. On the contrary, the ultrasound assessment of OP alone before labour does not appear useful since foetuses with OPP at onset of labour seem to have both labour and delivery outcome similar to the OAP, particularly in case of anterior spine position [ 31 ]. The early intrapartum detection of OPP could anticipate and increase the possibilities of performing a fetal head manual rotation to OAP. In fact, some studies (despite none RCT) reported data about intrapartum digital or manual rotation of the OPP in order to increase spontaneous deliveries and reduce CS and instrumental deliveries [ 15 ]. Despite the fact that all the studies agreed with favorable findings of these procedures, only few maternity care practitioners use this procedure since the successful rotation depends on the experience and skill of the practitioner, on whether it is used selectively or routinely and on the timing of its performance [ 15 ].

Acknowledgments

All authors acknowledge midwives for the strictly intrapartum collaboration. The authors thank all the equip of the Delivery Room of the Unit of Gynaecology and Obstetrics Clinic of Padua.

Conflict of Interests

The authors declare that there is no conflict of interests regarding the publication of this paper.

Face Presentation

• First Online: 02 August 2023

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• Shubhra Agarwal 2 &
• Suchitra Pandit 3  

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Face presentation is defined as a cephalic presentation in which the presenting part is face and it occurs due to factors that lead to extension of of fetal head. It is a rare obstetric presentation and may not be encountered even in the entire carrier of an obstetrician.

• Face presentation
• Active phase of labor
• Prematurity
• Deflexed head
• Congenital malformations
• Dolichocephalic skull
• Mento-anterior
• Crichton’s method

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Department of Obstetrics and Gynaecology, TMMC&RC, Moradabad, India

Shubhra Agarwal

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Department of Obstetrics and Gynecology, Sarojini Naidu Medical College, Agra, Uttar Pradesh, India

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Agarwal, S., Pandit, S. (2023). Face Presentation. In: Garg, R. (eds) Labour and Delivery. Springer, Singapore. https://doi.org/10.1007/978-981-19-6145-8_6

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