Fetal Malpresentation and

Malposition
Fetal presentation describes which part of the fetus will enter through the cervix first,
while position is the orientation of the fetus compared to the maternal bony pelvis.
Presentations include vertex (the fetal occiput will present through the cervix first),
face, brow, shoulder, and breech. If a fetal limb is presenting next to the presenting
part (e.g., the hand is next to the head), this is known as a compound presentation.
Malpresentation refers to any presentation other than vertex, with the most common
being breech presentations. Vaginal delivery of a breech infant increases the risk for
head entrapment and hypoxia, so, especially in the United States, mothers are
generally offered a procedure to help manually rotate the baby to a head-down
position instead (known as an external cephalic version) or a planned cesarean
delivery.

Last updated: February 14, 2023

CONTENTS

Overview
Fetal Lie and Presentation
Position
Presenting Diameter
Diagnosis
Management of Cephalic and Compound Presentations
Risks and Management of Breech and Transverse Presentations
References

Overview
Definition
The “presenting part” refers to the part of the baby that will come through the
cervix first.
The position refers to how that body part (and thus the baby) is oriented within
the maternal pelvis.
The uterine fundus is typically roomier, so babies tend to orient themselves head
down so that their body and limbs occupy the larger portion of the uterus.

Clinical relevance
The maternal pelvis 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.
Certain presentation/positions are more difficult (or even impossible) to pass
through the pelvis 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
Uterine abnormalities (e.g., leiomyomas, uterine septa)
Narrow pelvis shapes
Fetal anomalies (e.g., hydrocephalus)
Placental anomalies (e.g., placenta previa, in which the placenta covers the
internal cervical os)
Amniotic fluid abnormalities:
Polyhydramnios (too much fluid)
Oligohydramnios (not enough fluid)
Malpresentation in a previous pregnancy

Epidemiology
Prevalence 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

Fetal Lie and Presentation

Fetal lie
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
first. Presentations include:
Longitudinal presentations:
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 flexed, with the occipital fontanel as the presenting
part
Face presentation
Brow presentation: forehead is the presenting part
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
Image by Lecturio. License: CC BY-NC-SA 4.0

Transverse and compound presentations

Transverse presentations:
Uncommon, but when they occur, the presenting fetal part is the shoulder.
If the cervix begins dilating, the arm may prolapse through the cervix.
In compound presentations, the most common situation is a hand or arm
presenting with the head.

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

Position
Position describes the relation of the fetal presenting part to the maternal bony
pelvis.

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
The fetal occiput is classified as being:
Anterior, posterior, or transverse in relation to the maternal pelvis
Being on the maternal right or left
Terminology examples:
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
Image by Lecturio. License: CC BY-NC-SA 4.0

Face and brow positions

Positions for face and brow presentations describe the position of the chin.
 The chin is referred to as the mentum.
Like occiput positions, mentum positions include:
Right or left mentum anterior
Right or left mentum posterior
Right or left mentum transverse
Direct mentum anterior or posterior

Breech and shoulder positions

Positions for breech presentations describe the position of the sacrum. Similar to
other presentations, they include anterior, posterior, and transverse and right,
left, and direct.
Positions for shoulder presentations/transverse lies describe the position of the
back; they are simply described as:
Dorso-superior (back up)
Dorso-inferior (back down)

Attitude and asynclitism

Attitude: amount of flexion or extension of the fetal head
Asynclitism:
Lateral deflection of the sagittal 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.

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.
Presenting Diameter
The presenting diameter refers to the width of the presenting part.
The maternal pelvis 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
Presenting diameters:
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

Diagnosis
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

Leopold’s maneuvers
 Techniques using abdominal palpation to determine the presentation of the
fetus
Techniques/maneuvers:
Palpate the uterine fundus and suprapubic area to determine the
lie/presentation:
The fetal head will be hard and round.
The lower body will be bulkier, nodular, and mobile.
Palpate the sides of the maternal abdomen to determine the orientation:
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.

Ultrasonography
Bedside abdominal ultrasonography can easily identify the fetal head and its
orientation.
Quick bedside ultrasonography on admission to labor and delivery to assess
fetal presentation is considered standard of care.
Findings:
The fetal head will typically encompass the entire window and appear like
a large white circle (the fetal skull).
Identification of the eyes can help determine position.
While it is good clinical practice to “lay hands” on the mother using Leopold’s
maneuvers, bedside ultrasonography should always be performed, if available,
to confirm findings because:
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
Image: “ Prenatal ultrasound scans image of the fetus” by Wijerathne BT, Rathnayake GK, Ranaraja SK.
License: CC BY 3.0

Vaginal and cervical examination

As the cervix dilates, the fetal fontanelles can be directly palpated.
Identifying the location of the fetal fontanelles allows the practitioner to establish
the position.
Technique:
Insert 1–2 fingers through the cervix posteriorly.
Sweep fingers along the fetal head moving anteriorly.
This maneuver allows for identification of the sagittal suture.
The fontanelles are then identified by moving along the sagittal suture.
Management of Cephalic and Compound
Presentations
Vertex presentations
Expectant management
All have high chances of successful vaginal delivery.

Compound presentations
Management:
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 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
(CD) should be performed.
Complications:
Prolonged labor
Umbilical cord prolapse
Increased maternal morbidity from lacerations
Ischemia of the compound part

Brow presentations
The majority spontaneously convert to a vertex presentation.
Expectant management
Cesarean delivery may be required if labor is prolonged.

Face presentations
 Management depends on the position.
Mentum anterior (chin facing the maternal pubic bone):
Expectant management
Can be delivered vaginally by an experienced provider
Cesarean delivery may be required.
Mentum posterior (MP; chin facing the maternal sacrum):
Head is fully extended and unable to pass through the birth canal.
Normally, the fetal head flexes as it passes under the pubic bone; however,
this is impossible in an MP position.
Cesarean delivery is always required (unless the infant spontaneously
rotates to a mentum anterior (MA) position).

Risks and Management of Breech and

Transverse Presentations
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
progresses. At different gestational ages, the prevalence of breech presentations
is:
< 28 weeks: 20%–25%
32 weeks: 10%–15%
Term (> 37 weeks): 3%
Spontaneous version is possible even at > 40 weeks.
Factors that ↑ chance of spontaneous version:
Flexed fetal legs
Polyhydramnios
Longer umbilical cord
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 malformations
Torticollis
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.
Causes compression of the umbilical cord running past the head (between the
delivered umbilicus and the undelivered placenta)
Leads to hypoxia until head is delivered → ↑ risk of fetal death
Occurs because the fetal head is the largest part of the fetus and thus the most
difficult to squeeze beneath the pubic bone:
The cervix may not be fully dilated enough to accommodate the head.
The fetal head may not fit through the bony pelvis.
The mother’s expulsive efforts are unable to quickly deliver the head.
Other risks of vaginal breech delivery:
Umbilical cord prolapse during labor → requires emergent CD
Birth injuries to the fetus (e.g., brachial plexus 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 (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.
Criteria for selecting low-risk women for planned vaginal breech delivery:
Frank or complete breech presentation with no hyperextension of the fetal
head on ultrasonography
No contraindications to a vaginal birth
No prior CDs
Prior successful vaginal deliveries (i.e., multiparity)
Gestational age ≥ 36 weeks
Spontaneous labor
Normal bony pelvis shown on X-ray
Estimated fetal weight between approximately 2500 and 3500 grams
(exact range varies based on clinician)
Breech extraction of a 2nd twin:
Immediately after delivery of the 1st twin in the cephalic presentation, the
physician reaches up into the uterus, manually grabs the infant's legs, and
gently guides them down through the birth canal while the cervix 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.
Success rate:
Approximately 50%–60% (higher in multiparous than in nulliparous
women)
In 1 large study, after a successful version:
97% of infants remained cephalic at birth.
86% delivered vaginally.
Plan:
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.
Typically done at 37 weeks (balances risks and benefits):
Infant is full term in case emergent CD is required because of
complications from the procedure (e.g., placental abruption).
Better ratio of infant size to fluid level than later in pregnancy
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.
After an unsuccessful version, the mother typically is scheduled for a
planned CD at 39 weeks.
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.
Contraindications for ECV:
Another contraindication for a vaginal delivery (e.g., placenta previa)
Severe oligohydramnios
Nonreassuring fetal monitoring prior to the procedure
A hyperextended fetal head
Significant fetal or uterine anomalies
Multiple gestations (e.g., twins)
 Risks:
Placental abruption: the pressure placed on the uterus during the
procedure can result in premature separation of the placenta from the
uterus:
Leads to fetal and maternal hemorrhage
An immediate CD is required.
Premature rupture of membranes (PROM): the pressure placed on the
uterus during the procedure can result in rupture of membranes:
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 and requires
immediate/emergent CD.
Fetal distress:
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
Scheduled at 39 weeks' gestational age (WGA) if the infant is known to be in the
breech presentation.
Alternative option to attempting ECV
Compared to a vaginal delivery of a cephalic infant, CD has a higher risk for:
Postpartum hemorrhage
Postpartum endomyometritis
Maternal injury
Longer recovery time postpartum
Complications in future pregnancies (e.g., placenta previa,
placenta accreta, uterine rupture)
Indications for CD with breech presentations:
Maternal request (mother declines ECV attempt)
ECV contraindicated
ECV unsuccessful
Fetal distress during labor
Prolonged 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.
References

1. 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
2. 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
3. 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
4. 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
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