Abnormal Position and Presentation Complications
Under normal circumstances, a baby is in the cephalic (vertex) position before delivery. In the cephalic position, the baby’s head is at the lower part of the abdomen in preparation for child birth; subsequently, a head-first birth occurs. However, some babies present differently before delivery. In these cases, abnormal presentations place the baby at risk of experiencing umbilical cord problems and/or a birth trauma. Types of abnormal fetal positions and presentations include the following. We’ll cover each in more detail on this page.
- Compound Presentation
- Limb Presentation
- Occipitoposterior (OP) Position
- Breech Presentation (Footling Breech, Kneeling Breech, Frank Breech, and Complete Breech)
- Face Presentation (Mentum Anterior, Mentum Posterior, and Mentum Transverse)
- Brow Presentation
- Shoulder Presentation or Transverse Lie
- Oskie Presentation
What Way Should a Baby Come Out During Birth?
Vertex presentation is the ‘normal’ way that a baby is typically positioned for birth, and the safest way for the baby to be born. In vertex presentation, the baby is positioned head-first with their occiput (the part of the head close to the base of the skull) entering the birth canal first. In this position, the baby’s chin is tucked into their chest and they are facing the mother’s back (occipito-anterior position). Any position other than vertex position is abnormal and can make vaginal delivery much more difficult or sometimes impossible. If a baby’s chin isn’t tucked into their chest, they may come out face-first (face presentation), which can cause birth injury.
What Happens if a Baby Isn’t in the Vertex Position During Birth?
Before delivery, it is critical that the fetus is in the standard vertex presentation and within the normal range for weight and size. This helps ensure the safety of both baby and mother during labor. When the baby’s size or position is abnormal, physician intervention is usually warranted. This may mean simple manual procedures to help reposition the baby or, in many cases, a planned C-section delivery. The failure of healthcare professionals to identify and quickly resolve issues related to fetal size, weight, and presentation is medical malpractice. There are numerous complications related to abnormal weight, size, abnormal position or presentation.
In the safest presentation (vertex presentation), the baby is born head first, with the rest of the body following. In a compound presentation, however, there are multiple presenting parts. Most commonly, this means that the baby’s head and an arm come out first at the same time. Sometimes compound presentation can occur with twins where the head of the first twin presents with the extremity of the second twin.
Risk factors for compound presentation include:
- Intrauterine growth restriction (IUGR)
- Multiple gestation (twins, triplets, etc.)
- A large pelvis
- External cephalic version
- Rupture of membranes at high station
Compound presentations can be detected via ultrasound before the mother’s water breaks. During labor, compound presentation is identified as an irregular finding during cervical examination.
If a mother has polyhydramnios, the risk of compound presentation is higher, as the flow of amniotic fluid when the membranes rupture can sweep extremities into the birth canal, or cause a cord prolapse, which is a medical emergency. If compound presentation continues, it is likely to cause dystocia (the baby becoming stuck in the birth canal), which is also a medical emergency. Often, the safest way to deliver a baby with compound presentation is C-section, because complications like dystocia and cord prolapse carry risks of severe adverse outcomes, including cerebral palsy, intellectual and developmental disabilities, and hypoxic-ischemic encephalopathy (HIE).
Limb presentation during childbirth means that the part of the baby’s body that emerges first is a limb – an arm or a leg. Babies with limb presentation can’t be delivered vaginally; they must be delivered quickly via emergency C-section. Limb presentation poses a large risk for dystocia (the baby getting stuck on the mother’s pelvis), which is a medical emergency.
Occipitoposterior (OP) Position
Approximately 1 out of 10 babies are in a posterior position rather than an anterior position, which is called an occipitoposterior (OP) position. This means the baby is in a head first position with the back part of her head turned towards the mother’s sacrum (back), or rotated to the left (right occipitoposterior position (ROP)), or to the left (left occipitoposterior position (LOP)) of the sacroiliac joint. This condition occurs in mothers who have problems with their pelvis, such as android, anthropoid or contracted pelvis. Occipitoposterior position increases the baby’s risk of experiencing a prolonged labor, prolapsed umbilical cord, and use of delivery instruments, such as forceps and vacuum extractors. These conditions can cause the baby to experience brain bleeds, a lack of oxygen to her brain and birth asphyxia.
Since vacuum extractors and forceps are very dangerous devices that attach directly to the baby’s head, they increase the baby’s risk of suffering a brain bleed. An umbilical cord prolapse is an obstetrical emergency because when a prolapse occurs, the cord is exiting in front of the baby in the birth canal, which usually causes the cord to become compressed between the baby and the mother. If the cord is completely compressed, it means the baby will not be receiving any oxygen-rich blood from her mother. Cord compression and oxygen deprivation will manifest on the fetal heart rate monitor as nonreassuring tracings. When this occurs, the baby must be delivered immediately by emergency C-section to prevent brain damage from birth asphyxia.
Indeed, when OP position is present, a C-section delivery will prevent oxygen deprivation in the baby caused by prolonged labor, an umbilical cord prolapse and forceps and vacuum extractor use. The C-section can prevent the baby from having lifelong conditions such as hypoxic ischemic encephalopathy (HIE), permanent brain damage, seizures and cerebral palsy.
Video: Posterior Position
Breech presentation is normal throughout pregnancy. However, by the 37th week, the baby should turn to the cephalic position in time for labor. A breech presentation is when a baby’s buttocks or legs are positioned to descend the birth canal first. Breech positions are dangerous because they can cause a lack of oxygen to the baby’s brain due to a prolapsed umbilical cord, traumatic head injury, spinal cord fracture and problems with labor.
In fact, when a baby is in a breech presentation, a vaginal delivery is more likely to result in her death than a C-section delivery. In a recent study, researchers found that the likelihood of dying was 10 times higher for breech babies delivered vaginally than for those who were delivered by C-section.
There are 4 types of breech positions:
- Footling breech presentation: In footling position, one or both feet come first, with the buttocks at a higher position than the feet.
- Kneeling breech presentation: This is when the baby has one or both legs extended at the hips and flexed at the knees.
- Frank breech presentation: This is when the baby’s buttocks present first, and her legs are flexed at the hip and extended at the knees, with the feet near the ears.
- Complete breech presentation: In this position, the baby’s hips and knees are flexed so that the baby is sitting cross-legged, with her feet beside her buttocks.
When a baby is in breech position, physicians often try to maneuver the baby into a head first position. This should only be attempted if fetal heart tracings are normal (the baby is not in distress). The only type of breech position that may allow for a vaginal delivery is frank breech, and the following conditions must be met:
- The baby’s heart rate is being closely monitored and the baby is not in distress.
- Cephalopelvic disproportion (CPD) is not present; x-rays and ultrasound show that the size of the mother’s pelvis will allow a safe vaginal birth.
- The hospital is equipped for and the physician is skilled in performing an emergency C-section.
If these conditions are not present, vaginal birth should not be attempted. Most experts recommend C-section delivery for all types of breech positions because it is the safest method of delivery and it helps avoid birth injuries. Mismanaged breech birth can cause a baby to have the following conditions:
- Brain bleeds, intracranial hemorrhages
- Spinal cord fractures
- Hypoxic ischemic encephalopathy (HIE)
- Cerebral palsy
- Intellectual disabilities
- Developmental delays
A face presentation is when the face is the presenting part of the baby. In this position, the baby’s neck is deflexed (extended backward) so that the back of the head touches the baby’s back. This prevents head engagement and descent of the baby through the birth canal. In some cases of face presentation, the trauma of a vaginal delivery causes face deformation and fluid build-up (edema) in the face and upper airway, which often means the baby will need a breathing tube placed in her airway to maintain airway patency and help her breathe.
There are three types of face presentation:
- Mentum anterior (MA): In this position, the chin is facing the front of the mother.
- Mentum posterior (MP): The chin is facing the mother’s back, pointing down towards her buttocks in mentum posterior position. In this position, the baby’s head, neck and shoulders enter the pelvis at the same time, and the pelvis is usually not large enough to accommodate this. Also, an open fetal mouth can push against the bone (sacrum) at the upper and back part of the pelvis, which also can prevent descent of the baby through the birth canal.
- Mentum transverse (MT): The baby’s chin is facing the side of the birth canal in this position.
Trauma almost always occurs with vaginal delivery of a baby whose face is presenting, so parents must be warned that their baby will be very bruised and that a C-section is available to avoid the trauma.
Babies presenting face-first can sometimes be delivered vaginally, as long as the baby is in MA position. On the other hand, safe vaginal delivery of a term-sized infant in persistent MP position is impossible due to the presenting part of the baby compared to the size of the mother’s pelvis. When a baby is in MP position, she must be delivered by C-section. If the baby is in MT position she must also be delivered by C-section. About 35% of babies in the MP position will spontaneously convert to the MA position during the course of labor, and the majority of babies in the MT position convert, which makes vaginal delivery a possibility. If the baby is in the MA position and vaginal delivery is thus able to proceed, engagement of the presenting part of the baby probably won’t occur until the face is at a +2 station.
Indeed, the management of face presentation requires close observation of the progress of labor due to the high incidence of CPD when face presentation is present. In face presentation, the diameter of the presenting part of the head is, on average, 0.7 cm greater than in the normal vertex position.
In any face presentation situation, if progress in dilation and descent ceases despite adequate contractions, delivery must occur by C-section. In fact, when face presentation occurs, experts recommend liberal use of C-section.
Since there is an increased risk of trauma to the baby when the face presents, the physician should not try to rotate the baby internally. In addition, the physician must not use vacuum extractors or manual extraction (grasping the baby with hands) to extract the baby from the uterine cavity. Furthermore, midforceps (forcep extraction when the baby’s station is above +2 cm, but the head is engaged) should never be used. Outlet forceps should only be used by experienced physicians, but these forceps increase the risk of trauma to the baby and brain bleeds.
Listed below are complications that can occur if face presentation is mismanaged by the medical team:
- Prolonged labor
- Facial trauma
- Facial and upper airway edema (fluid build-up in the face, often caused by trauma)
- Skull molding (abnormal head shape that results from pressure on the baby’s head during childbirth)
- Respiratory distress or difficulty in ventilation (the baby being able to move air in and out of lungs) due to upper airway trauma and edema
- Spinal cord injury
- Abnormal fetal heart rate patterns
- 10-fold increase in fetal compromise
- Brain bleeds
- Intracranial hemorrhages
- Hypoxic ischemic encephalopathy (HIE)
- Permanent brain damage
- Cerebral palsy
- Intellectual disabilities
- Developmental delays
Video: Face Presentation
Brow presentation is similar to face presentation, but the baby’s neck is less extended. A fetus in brow presentation has the chin untucked, and the neck is extended slightly backwards. As the term “brow presentation” suggests, the brow (forehead) is the part that is situated to go through the pelvis first. Vaginal delivery can be difficult or impossible with brow presentation, because the diameter of the presenting part of the head may be too big to safely fit through the pelvis.
Shoulder Presentation (Transverse Lie)
Shoulder presentation (transverse lie) is when the arm, shoulder or trunk of the baby enter the birth canal first. When a baby is in a transverse lie position during labor, the only way to successfully deliver her is by C-section delivery. Mothers who have polyhydramnios (too much amniotic fluid), are pregnant with more than one baby, have placenta previa or a small fetus (which can occur when the baby has intrauterine growth restriction (IUGR)) are at risk of the baby being in a transverse lie position. Once the membranes rupture, there is an increased risk of umbilical cord prolapse in this position. Thus, a C-section should ideally be performed before the membranes break. Failure to quickly deliver the baby by C-section when transverse lie presentation is present can cause severe birth asphyxia due to cord compression and trauma to the baby. This can cause hypoxic ischemic encephalopathy (HIE), seizures, permanent brain damage and cerebral palsy.
Legal Help for Birth Injuries from Abnormal Position or Presentation
Michigan-Based Birth Injury Attorneys with a National Presence
The award-winning birth injury attorneys at Reiter & Walsh, PC have over 100 years of joint experience handling birth trauma cases related to abnormal position or presentation. If you believe your loved one’s birth injury resulted from an instance of medical malpractice, you may be entitled to compensation from a medical malpractice or personal injury case. Reiter & Walsh, P.C. handles cases all over the country, in states such as Michigan, Ohio, Pennsylvania, Texas, Tennessee, Wisconsin, Arkansas, Mississippi, Washington D.C., and more. During your free legal consultation, our birth injury attorneys will discuss your case with you, determine in negligence caused your loved one’s injuries, identify the negligent party, and discuss your legal options with you.
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The information presented above is intended only to be a general educational resource. It is not intended to be (and should not be interpreted as) medical advice.