FETAL POSITION

Ina S. Irabon, MD, FPOGS, FPSREI, FPSGE

Obstetrics and Gynecology
Reproductive Endocrinology and Infertility
Laparoscopy and Hysteroscopy
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 REFERENCE

• Cunningham FG, Leveno KJ, Bloom SL, Spong CY,

Dashe JS, Hoffman BL, Casey BM, Sheffield JS
(eds).William’s Obstetrics 24th edition (20140;
chapter 22 Normal Labor
• Sumpaico WW, Ocampo-Andres IS, Blanco-Capito
LR, Diamante An, Gamilla ZN. (eds). Textbook of
Obstetrics 3rd edition. Chapter 24 The Passenger
 OUTLINE

1. Fetal attitude
2. Fetal lie
transverse
longitudinal
3. Fetal presentation
Cephalic
breech
compound
shoulder
4. Fetal position
5. Leopold’s maneuvers
 THE PASSENGER

• Fetal attitude:
àFetal posture or habitus
àRelationship of the fetal head
to fetal back or extremities

à“universal flexion”
à As a rule, the fetus forms an ovoid
mass that corresponds roughly to the
shape of the uterine cavity -- fetus
becomes folded or bent upon itself in
such a manner that the back
becomes markedly convex; the head
is sharply flexed so that the chin is
almost in contact with the chest; the
thighs are flexed over the abdomen;
and the legs are bent at the knees.
 s relative to ume
the increasing
decreasesfetal mass.toAsthe
relative a result,
increasing fetal mass. As a result,
alls are apposed more closely Abnormal exceptions to this at
the uterine wallstoare
theapposed
fetal parts.
more closely to the fetal parts.
ng by the breech, the fetus often becomes progressively more extenb
If presenting by changes polarity
the breech, the fetus often changes polarity
face presentation (see Fig. 22-1).
fa
of the roomierto make
ic pole. As discussed
FETAL ATTITUDE
fundususeforofitsthe
in Chapter
bulkier
28As
and more
roomier fundus for its bulkier and more
(p.discussed change in fetal attitude from a ch
559), the in Chapter c
mobile podalic pole. 28 (p. 559), the
breech presentation decreases with presentation (extended) contour of the vertebra
gestational age.decreases (e
incidence of breech with gestational age.
tes 25 percent Itatapproximates
28 weeks, 17 percent
25 percentat 30atweeks,
28 weeks, 17 percent at 30 weeks,
Head flexed Head extended ■ Fet
Position
of an
of the
right or
Accordi
there m
or left.
tum), an
points i
sentatio
22-6).
may be
tion, th
B A C B D C left and
D
 THE PASSENGER

• Fetal Lie:

• Relationship of the long

axis of the fetus to the
long axis of the maternal
abdomen

• C u n n in g h a m FG , Le v e n o K J , B lo o m S L, S p o n g C Y , D a sh e
J S , H o ffm a n B L, C a se y B M , S h e ffie ld J S (e d s).W illia m ’s
O b ste tric s 2 4 th e d itio n (2 0 1 4 0 ; c h a p te r 2 2 N o rm a l La b o r
• S u m p a ic o W W , O c a m p o -A n d re s IS , B la n c o -C a p ito LR ,
D ia m a n te A n , G a m illa ZN . (e d s). Te xtb o o k o f O b ste tric s 3 rd
e d itio n . C h a p te r 2 4 Th e P a sse n g e r
• Fetal lie: oblique
 THE PASSENGER

• Fetal presentation

• Portion of the body of

the fetus that is foremost
within the birth canal or
in closest proximity to it

• Cephalic, breech,
shoulder, compound
• C u n n in g h a m FG , Le v e n o K J , B lo o m S L, S p o n g C Y , D a sh e
J S , H o ffm a n B L, C a se y B M , S h e ffie ld J S (e d s).W illia m ’s
th
O b ste tric s 2 4 e d itio n (2 0 1 4 0 ; c h a p te r 2 2 N o rm a l La b o r
• S u m p a ic o W W , O c a m p o -A n d re s IS , B la n c o -C a p ito LR ,
rd
D ia m a n te A n , G a m illa ZN . (e d s). Te xtb o o k o f O b ste tric s 3
e d itio n . C h a p te r 2 4 Th e P a sse n g e r
 THE PASSENGER

• Cephalic presentation
1. Vertex/occiput
2. Sinciput/military
3. Brow
4. Face
 CEPHALIC PRESENTATION

• vertex or occiput presentation - occipital fontanel is the

presenting part

• Face presentation - face is foremost in the birth canal;

fetal neck may be sharply extended so that the occiput
and back come in contact.
•
• Sinciput presentation- fetal head partially flexed, with
the anterior (large) fontanel, or bregma, presenting

• Brow presentation –fetal head partially extended, with

the brow presenting
• C u n n in g h a m FG , Le v e n o K J , B lo o m S L, S p o n g C Y , D a sh e
J S , H o ffm a n B L, C a se y B M , S h e ffie ld J S (e d s).W illia m ’s
O b ste tric s 2 4 th e d itio n (2 0 1 4 0 ; c h a p te r 2 2 N o rm a l La b o r
• S u m p a ic o W W , O c a m p o -A n d re s IS , B la n c o -C a p ito LR ,
D ia m a n te A n , G a m illa ZN . (e d s). Te xtb o o k o f O b ste tric s 3 rd
e d itio n . C h a p te r 2 4 Th e P a sse n g e r
 THE PASSENGER

• Breech presentation
• àbitronchanteric diameter
presents

1. Frank
2. Complete
3. Incomplete/
footling
• C u n n in g h a m FG , Le v e n o K J , B lo o m S L, S p o n g C Y , D a sh e
J S , H o ffm a n B L, C a se y B M , S h e ffie ld J S (e d s).W illia m ’s
th
O b ste tric s 2 4 e d itio n (2 0 1 4 0 ; c h a p te r 2 2 N o rm a l La b o r
• S u m p a ic o W W , O c a m p o -A n d re s IS , B la n c o -C a p ito LR ,
rd
D ia m a n te A n , G a m illa ZN . (e d s). Te xtb o o k o f O b ste tric s 3
e d itio n . C h a p te r 2 4 Th e P a sse n g e r
 THE PASSENGER

• Shoulder presentation
shoulder or acromion is presenting
into the pelvic inlet;
Bisacromial diameter (11cm)
presents

• Compound Presentation
Fetal hand or foot prolapses
alongsidethe prresenting vertex or
breech
• C u n n in g h a m FG , Le v e n o K J , B lo o m S L, S p o n g C Y , D a sh e
J S , H o ffm a n B L, C a se y B M , S h e ffie ld J S (e d s).W illia m ’s
th
O b ste tric s 2 4 e d itio n (2 0 1 4 0 ; c h a p te r 2 2 N o rm a l La b o r
• S u m p a ic o W W , O c a m p o -A n d re s IS , B la n c o -C a p ito LR ,
rd
D ia m a n te A n , G a m illa ZN . (e d s). Te xtb o o k o f O b ste tric s 3
e d itio n . C h a p te r 2 4 Th e P a sse n g e r
 THE PASSENGER

• Fetal position: Relationship of the chosen portion of the

fetal presenting part in reference to one of the 4
quadrants or tranverse diameter of birth canal
ties of each of the three presentations as shown in Figures
to 22-6. Thus, in an occiput presentation, the presenta-
position, and variety may be FETAL
abbreviated in clockwise
POSITION
on as:

OA ANTERIOR

ROA LOA

TRANSVERSE
ROT LOT
MATERNAL
MATERNAL LEFT
RIGHT
ROP LOP

OP POSTERIOR
•
A
C u n n in g h a m FG , Le v e n o K J , B lo o m S L, S p o n g C Y , D a sh e
J S , H o ffm a n B L, C a se y B M , S h e ffie ld J S (e d s).W illia m ’s
th
O b ste tric s 2 4 e d itio n (2 0 1 4 0 ; c h a p te r 2 2 N o rm a l La b o r
• S u m p a ic o W W , O c a m p o -A n d re s IS , B la n c o -C a p ito LR ,
rd
D ia m a n te A n , G a m illa ZN . (e d s). Te xtb o o k o f O b ste tric s 3

roximately two thirds of allFIGURE

vertex presentations are in the LEFTlie.
22-2 Longitudinal
e d itio n . C h a p te r 2 4 Th e P a sse n g e r
OCCIPUT presentation. A. L
VertexANTERIOR
 FETAL POSITION

• Approximately two thirds of all vertex presentations

are in the left occiput position, and one third in the
right.

• C u n n in g h a m FG , Le v e n o K J , B lo o m S L, S p o n g C Y , D a sh e
J S , H o ffm a n B L, C a se y B M , S h e ffie ld J S (e d s).W illia m ’s
th
O b ste tric s 2 4 e d itio n (2 0 1 4 0 ; c h a p te r 2 2 N o rm a l La b o r
• S u m p a ic o W W , O c a m p o -A n d re s IS , B la n c o -C a p ito LR ,
rd
D ia m a n te A n , G a m illa ZN . (e d s). Te xtb o o k o f O b ste tric s 3
e d itio n . C h a p te r 2 4 Th e P a sse n g e r
 PRACTICE

LEFT OCCIPUT ANTERIOR LEFT OCCIPUT POSTERIOR

RIGHT OCCIPUT POSTERIOR RIGHT OCCIPUT TRANSVERSE

 FETAL POSITION

• In defining position, the following determining points

are used:
• O – occiput (cephalic/vertex presentation)
• M – mentum or chin (face presentation)
• S – sacrum (breech presentation)
• A – acromion or scapula (shoulder presentation)

• C u n n in g h a m FG , Le v e n o K J , B lo o m S L, S p o n g C Y , D a sh e
J S , H o ffm a n B L, C a se y B M , S h e ffie ld J S (e d s).W illia m ’s
O b ste tric s 2 4 th e d itio n (2 0 1 4 0 ; c h a p te r 2 2 N o rm a l La b o r
• S u m p a ic o W W , O c a m p o -A n d re s IS , B la n c o -C a p ito LR ,
D ia m a n te A n , G a m illa ZN . (e d s). Te xtb o o k o f O b ste tric s 3 rd
e d itio n . C h a p te r 2 4 Th e P a sse n g e r
 PRACTICE
Left mentum Right mentum Right mentum
anterior anterior posterior

Right
dorsoacromion
DIAGNOSIS OF FETAL PRESENTATION
AND POSITION
• Several methods can be used to diagnose fetal
presentation and position:
1. abdominal palpation: Leopold’s maneuvers
2. vaginal examination
3. Auscultation
4. Sonography/ultrasound
5. Rarely: plain radiographs, computed tomography,
or magnetic resonance imaging may be used.

• C u n n in g h a m FG , Le v e n o K J , B lo o m S L, S p o n g C Y , D a sh e
J S , H o ffm a n B L, C a se y B M , S h e ffie ld J S (e d s).W illia m ’s
O b ste tric s 2 4 th e d itio n (2 0 1 4 0 ; c h a p te r 2 2 N o rm a l La b o r
• S u m p a ic o W W , O c a m p o -A n d re s IS , B la n c o -C a p ito LR ,
D ia m a n te A n , G a m illa ZN . (e d s). Te xtb o o k o f O b ste tric s 3 rd
e d itio n . C h a p te r 2 4 Th e P a sse n g e r
 VAGINAL EXAMINATION

• With the onset of labor and after cervical dila-

tation, vertex presentations and their positions are
recognized by palpation of the various fetal sutures
and fontanels.

• Face and breech presentations are identified by

palpation of facial features and fetal sacrum

• C u n n in g h a m FG , Le v e n o K J , B lo o m S L, S p o n g C Y , D a sh e
J S , H o ffm a n B L, C a se y B M , S h e ffie ld J S (e d s).W illia m ’s
O b ste tric s 2 4 th e d itio n (2 0 1 4 0 ; c h a p te r 2 2 N o rm a l La b o r
• S u m p a ic o W W , O c a m p o -A n d re s IS , B la n c o -C a p ito LR ,
D ia m a n te A n , G a m illa ZN . (e d s). Te xtb o o k o f O b ste tric s 3 rd
e d itio n . C h a p te r 2 4 Th e P a sse n g e r
• First, the examiner pelvic i
inserts two fingers into stance,
the vagina and the as “floa
presenting part is does n
found. directed
fetal he
either t
• Second, if the vertex is cowork
presenting, the fingers nullipa
are directed posteriorly head en
not aff
and then swept spontan
forward over the fetal
head toward the Asyncl
maternal symphysis FIGURE 22-9 Locating the sagittal suture by vaginal examination. accomm
pelvic
pubis • C u n n in g h a m FG , Le v e n o K J , B lo o m S L, S p o n g Cwhile Y , Dremaining
a sh e parallel to
J S , H o ffm a n B L, C a se y B M , S h e ffie ld J S (e d s).W illia m ’s
The Ocardinal
b ste tricmovements ofitio
s 2 4 th e d labor
n r(2are
0 1 engagement, r 2 2 N o rm way
4 0 ; c h a p tedescent, between
a l La b o r the symphysis
S u m p a ic o W W , O c a m p o -A n d re s IS , B la n c o -C a sagittal
flexion,
•
internal rotation, extension, external rotation, and p ito LRsuture
D ia m a n te A n , G a m illa ZN . (e d s). Te xtb o o k o f O b ste tric s 3 rd
, frequently is
expulsion
e d itio(Fig. h a p teDuring
n . C22-11). r 2 4 Thlabor,
e P a these
sse n g movements
er not the promontory or anterio
 Descent
transverse diameter in an occiput presentation—passes through
the pelvic inlet is designated engagement. The fetal head may This movement is the first re
engage during the last few weeks of pregnancy or not until In nulliparas, engagement m
after labor commencement. In many multiparous and some of labor, and further descen
nulliparous women, the fetal head is freely movable above the of the second stage. In mu
with engagement. Descent i
of four
onic flui
• Next, the positions of the dus upo
two fontanels are (3) bea
ascertained àfingers are abdomin
passed to the most and stra
anterior extension of the
sagittal suture, and the Flexion
fontanel encountered As soon
there is examined and resistanc
identified. walls, or
• With a sweeping motion, With th
into mo
the fingers pass along the
thorax,
suture to the other end of occipito
the head until the other for the
fontanel is felt and FIGURE 22-10 Differentiating the fontanels by vaginal examination. (Figs. 22
differentiated
• C u n n in g h a m FG , Le v e n o K J , B lo o m S L, S p o n g C Y , D a sh e
J S , H o ffm a n B L, C a se y B M , S h e ffie ld J S (e d s).W illia m ’s
O b ste tric s 2 4 th e d itio n (2 0 1 4 0 ; c h a p te r 2 2 N o rm a l La b o r
• S u m p a ic o W W , O c a m p o -A n d re s IS , B la n c o -C a p ito LR ,
D ia m a n te A n , G a m illa ZN . (e d s). Te xtb o o k o f O b ste tric s 3 rd
e d itio n . C h a p te r 2 4 Th e P a sse n g e r
 VAGINAL EXAMINATION

• Last, the station, or

extent to which the
presenting part has
descended into the
pelvis, can also be
established at this
time

• Iliac spines: station 0 • C u n n in g h a m FG , Le v e n o K J , B lo o m S L, S p o n g C Y , D a sh e

J S , H o ffm a n B L, C a se y B M , S h e ffie ld J S (e d s).W illia m ’s
O b ste tric s 2 4 th e d itio n (2 0 1 4 0 ; c h a p te r 2 2 N o rm a l La b o r
• S u m p a ic o W W , O c a m p o -A n d re s IS , B la n c o -C a p ito LR ,
D ia m a n te A n , G a m illa ZN . (e d s). Te xtb o o k o f O b ste tric s 3 rd
e d itio n . C h a p te r 2 4 Th e P a sse n g e r
LEOPOLD’S MANEUVERS
 LEOPOLD’S MANEUVER

• Abdominal exam to
determine fetal
presentation

• C u n n in g h a m FG , Le v e n o K J , B lo o m S L, S p o n g C Y , D a sh e
J S , H o ffm a n B L, C a se y B M , S h e ffie ld J S (e d s).W illia m ’s
th
O b ste tric s 2 4 e d itio n (2 0 1 4 0 ; c h a p te r 2 2 N o rm a l La b o r
• S u m p a ic o W W , O c a m p o -A n d re s IS , B la n c o -C a p ito LR ,
rd
D ia m a n te A n , G a m illa ZN . (e d s). Te xtb o o k o f O b ste tric s 3
e d itio n . C h a p te r 2 4 Th e P a sse n g e r
 LEOPOLD’S MANEUVER

1. Leopold’s maneuver #1
(LM1)

• “Fundal grip”
• Uterine fundus is palpated to
detemine which fetal part
occupies the fundus

• Fetal head should be round

and hard, ballottable
• Breech presents as a large
nodular mass
• C u n n in g h a m FG , Le v e n o K J , B lo o m S L, S p o n g C Y , D a sh e
J S , H o ffm a n B L, C a se y B M , S h e ffie ld J S (e d s).W illia m ’s
O b ste tric s 2 4 th e d itio n (2 0 1 4 0 ; c h a p te r 2 2 N o rm a l La b o r
• S u m p a ic o W W , O c a m p o -A n d re s IS , B la n c o -C a p ito LR ,
D ia m a n te A n , G a m illa ZN . (e d s). Te xtb o o k o f O b ste tric s 3 rd
e d itio n . C h a p te r 2 4 Th e P a sse n g e r
 LEOPOLD’S MANEUVER

2. Leopold’s maneuver #2
(LM2)

• “Umbilical grip”
• Palpation of paraumbilical
areas or the sides of the uterus
• To determine which side is the
fetal back

• Fetal back feels like a hard,

resistant, convex structure
• Fetal small parts feel nodular,
irregular
• C u n n in g h a m FG , Le v e n o K J , B lo o m S L, S p o n g C Y , D a sh e
J S , H o ffm a n B L, C a se y B M , S h e ffie ld J S (e d s).W illia m ’s
O b ste tric s 2 4 th e d itio n (2 0 1 4 0 ; c h a p te r 2 2 N o rm a l La b o r
• S u m p a ic o W W , O c a m p o -A n d re s IS , B la n c o -C a p ito LR ,
D ia m a n te A n , G a m illa ZN . (e d s). Te xtb o o k o f O b ste tric s 3 rd
e d itio n . C h a p te r 2 4 Th e P a sse n g e r
 LEOPOLD’S MANEUVER

3. Leopold’s maneuver #3
(LM3)

• “Pawlik’s grip”
• Suprapubic palpation using
thumb and fingers just above
the symphysis pubis, to
determine fetal presentation
and station
• the differentiation between
head and breech is made as in
LM1

• *If presenting part is not

engaged, a movable structure
can be palpated
• C u n n in g h a m FG , Le v e n o K J , B lo o m S L, S p o n g C Y , D a sh e
J S , H o ffm a n B L, C a se y B M , S h e ffie ld J S (e d s).W illia m ’s
O b ste tric s 2 4 th e d itio n (2 0 1 4 0 ; c h a p te r 2 2 N o rm a l La b o r
• S u m p a ic o W W , O c a m p o -A n d re s IS , B la n c o -C a p ito LR ,
D ia m a n te A n , G a m illa ZN . (e d s). Te xtb o o k o f O b ste tric s 3 rd
e d itio n . C h a p te r 2 4 Th e P a sse n g e r
 LEOPOLD’S MANEUVER

4. Leopold’s maneuver #4 (LM4)

• “Pelvic grip”
• Palpation of the bilateral lower
quadrants to determine
engagement of the fetal
presenting part

• Fetal part is engaged: examiner’s

hands diverge
• Fetal head is not engaged:
examiner’s hands converge • C u n n in g h a m FG , Le v e n o K J , B lo o m S L, S p o n g C Y , D a sh e

• If fetal head is felt on same side of J S , H o ffm a n B L, C a se y B M , S h e ffie ld J S (e d s).W illia m ’s

O b ste tric s 2 4 th e d itio n (2 0 1 4 0 ; c h a p te r 2 2 N o rm a l La b o r

the fetal back à fetal head is well • S u m p a ic o W W , O c a m p o -A n d re s IS , B la n c o -C a p ito LR ,

D ia m a n te A n , G a m illa ZN . (e d s). Te xtb o o k o f O b ste tric s 3 rd
flexed e d itio n . C h a p te r 2 4 Th e P a sse n g e r
 SUMMARY / REVIEW

1. Fetal attitude
2. Fetal lie
transverse
longitudinal
3. Fetal presentation
Cephalic
breech
compound
shoulder
4. Fetal position
5. Leopold’s maneuvers