what is military presentation in birth

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

Key Points |

Abnormal fetal lie or presentation may occur due to fetal size, fetal anomalies, uterine structural abnormalities, multiple gestation, or other factors. Diagnosis is by examination or ultrasonography. Management is with physical maneuvers to reposition the fetus, operative vaginal delivery , or cesarean delivery .

Terms that describe the fetus in relation to the uterus, cervix, and maternal pelvis are

Fetal presentation: Fetal part that overlies the maternal pelvic inlet; vertex (cephalic), face, brow, breech, shoulder, funic (umbilical cord), or compound (more than one part, eg, shoulder and hand)

Fetal position: Relation of the presenting part to an anatomic axis; for transverse presentation, occiput anterior, occiput posterior, occiput transverse

Fetal lie: Relation of the fetus to the long axis of the uterus; longitudinal, oblique, or transverse

Normal fetal lie is longitudinal, normal presentation is vertex, and occiput anterior is the most common position.

Abnormal fetal lie, presentation, or position may occur with

Fetopelvic disproportion (fetus too large for the pelvic inlet)

Fetal congenital anomalies

Uterine structural abnormalities (eg, fibroids, synechiae)

Multiple gestation

Several common types of abnormal lie or presentation are discussed here.

Transverse lie

Fetal position is transverse, with the fetal long axis oblique or perpendicular rather than parallel to the maternal long axis. Transverse lie is often accompanied by shoulder presentation, which requires cesarean delivery.

Breech presentation

There are several types of breech presentation.

Frank breech: The fetal hips are flexed, and the knees extended (pike position).

Complete breech: The fetus seems to be sitting with hips and knees flexed.

Single or double footling presentation: One or both legs are completely extended and present before the buttocks.

Types of breech presentations

Breech presentation makes delivery difficult ,primarily because the presenting part is a poor dilating wedge. Having a poor dilating wedge can lead to incomplete cervical dilation, because the presenting part is narrower than the head that follows. The head, which is the part with the largest diameter, can then be trapped during delivery.

Additionally, the trapped fetal head can compress the umbilical cord if the fetal umbilicus is visible at the introitus, particularly in primiparas whose pelvic tissues have not been dilated by previous deliveries. Umbilical cord compression may cause fetal hypoxemia.

Predisposing factors for breech presentation include

Preterm labor

Uterine abnormalities

Fetal anomalies

If delivery is vaginal, breech presentation may increase risk of

Umbilical cord prolapse

Birth trauma

Perinatal death

Face or brow presentation

In face presentation, the head is hyperextended, and position is designated by the position of the chin (mentum). When the chin is posterior, the head is less likely to rotate and less likely to deliver vaginally, necessitating cesarean delivery.

Brow presentation usually converts spontaneously to vertex or face presentation.

Occiput posterior position

The most common abnormal position is occiput posterior.

The fetal neck is usually somewhat deflexed; thus, a larger diameter of the head must pass through the pelvis.

Progress may arrest in the second phase of labor. Operative vaginal delivery or cesarean delivery is often required.

Position and Presentation of the Fetus

If a fetus is in the occiput posterior position, operative vaginal delivery or cesarean delivery is often required.

In breech presentation, the presenting part is a poor dilating wedge, which can cause the head to be trapped during delivery, often compressing the umbilical cord.

For breech presentation, usually do cesarean delivery at 39 weeks or during labor, but external cephalic version is sometimes successful before labor, usually at 37 or 38 weeks.

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StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-.

StatPearls [Internet].

Delivery, face and brow presentation.

Julija Makajeva ; Mohsina Ashraf .

Affiliations

Last Update: January 9, 2023 .

Continuing Education Activity

Face and brow presentation is a malpresentation during labor when the presenting part is either the face or, in the case of brow presentation, it is the area between the orbital ridge and the anterior fontanelle. This activity reviews the evaluation and management of these two presentations and explains the role of the interprofessional team in managing delivery safely for both the mother and the baby.

Describe the mechanism of labor in the face and brow presentation.
Summarize potential maternal and fetal complications during the face and brow presentations.
Review different management approaches for the face and brow presentation.
Outline some interprofessional strategies that will improve patient outcomes in delivery cases with face and brow presentation issues.
Introduction

The term presentation describes the leading part of the fetus or the anatomical structure closest to the maternal pelvic inlet during labor. The presentation can roughly be divided into the following classifications: cephalic, breech, shoulder, and compound. Cephalic presentation is the most common and can be further subclassified as vertex, sinciput, brow, face, and chin. The most common presentation in term labor is the vertex, where the fetal neck is flexed to the chin, minimizing the head circumference.

Face presentation – an abnormal form of cephalic presentation where the presenting part is mentum. This typically occurs because of hyperextension of the neck and the occiput touching the fetal back. Incidence of face presentation is rare, accounting for approximately 1 in 600 of all presentations. [1] [2] [3]

In brow presentation, the neck is not extended as much as in face presentation, and the leading part is the area between the anterior fontanelle and the orbital ridges. Brow presentation is considered the rarest of all malpresentation with a prevalence of 1 in 500 to 1 in 4000 deliveries. [3]

Both face and brow presentations occur due to extension of the fetal neck instead of flexion; therefore, conditions that would lead to hyperextension or prevent flexion of the fetal neck can all contribute to face or brow presentation. These risk factors may be related to either the mother or the fetus. Maternal risk factors are preterm delivery, contracted maternal pelvis, platypelloid pelvis, multiparity, previous cesarean section, black race. Fetal risk factors include anencephaly, multiple loops of cord around the neck, masses of the neck, macrosomia, polyhydramnios. [2] [4] [5]

These malpresentations are usually diagnosed during the second stage of labor when performing a digital examination. It is possible to palpate orbital ridges, nose, malar eminences, mentum, mouth, gums, and chin in face presentation. Based on the position of the chin, face presentation can be further divided into mentum anterior, posterior, or transverse. In brow presentation, anterior fontanelle and face can be palpated except for the mouth and the chin. Brow presentation can then be further described based on the position of the anterior fontanelle as frontal anterior, posterior, or transverse.

Diagnosing the exact presentation can be challenging, and face presentation may be misdiagnosed as frank breech. To avoid any confusion, a bedside ultrasound scan can be performed. [6] The ultrasound imaging can show a reduced angle between the occiput and the spine or, the chin is separated from the chest. However, ultrasound does not provide much predicting value in the outcome of the labor. [7]

Anatomy and Physiology

Before discussing the mechanism of labor in the face or brow presentation, it is crucial to highlight some anatomical landmarks and their measurements.

Planes and Diameters of the Pelvis

The three most important planes in the female pelvis are the pelvic inlet, mid pelvis, and pelvic outlet.

Four diameters can describe the pelvic inlet: anteroposterior, transverse, and two obliques. Furthermore, based on the different landmarks on the pelvic inlet, there are three different anteroposterior diameters, named conjugates: true conjugate, obstetrical conjugate, and diagonal conjugate. Only the latter can be measured directly during the obstetric examination. The shortest of these three diameters is obstetrical conjugate, which measures approximately 10.5 cm and is a distance between the sacral promontory and 1 cm below the upper border of the symphysis pubis. This measurement is clinically significant as the fetal head must pass through this diameter during the engagement phase. The transverse diameter measures about 13.5cm and is the widest distance between the innominate line on both sides.

The shortest distance in the mid pelvis is the interspinous diameter and usually is only about 10 cm.

Fetal Skull Diameters

There are six distinguished longitudinal fetal skull diameters:

Suboccipito-bregmatic: from the center of anterior fontanelle (bregma) to the occipital protuberance, measuring 9.5 cm. This is the presenting diameter in vertex presentation.
Suboccipito-frontal: from the anterior part of bregma to the occipital protuberance, measuring 10 cm
Occipito-frontal: from the root of the nose to the most prominent part of the occiput, measuring 11.5cm
Submento-bregmatic: from the center of the bregma to the angle of the mandible, measuring 9.5 cm. This is the presenting diameter in face presentation where the neck is hyperextended.
Submento-vertical: from the midpoint between fontanelles and the angle of the mandible, measuring 11.5cm
Occipito-mental: from the midpoint between fontanelles and the tip of the chin, measuring 13.5 cm. It is the presenting diameter in brow presentation.

Cardinal Movements of Normal Labor

Neck flexion
Internal rotation
Extension (delivers head)
External rotation (Restitution)
Expulsion (delivery of anterior and posterior shoulders)

Some of the key movements are not possible in the face or brow presentations.

Based on the information provided above, it is obvious that labor will be arrested in brow presentation unless it spontaneously changes to face or vertex, as the occipito-mental diameter of the fetal head is significantly wider than the smallest diameter of the female pelvis. Face presentation can, however, be delivered vaginally, and further mechanisms of face delivery will be explained in later sections.

Indications

As mentioned previously, spontaneous vaginal delivery can be successful in face presentation. However, the main indication for vaginal delivery in such circumstances would be a maternal choice. It is crucial to have a thorough conversation with a mother, explaining the risks and benefits of vaginal delivery with face presentation and a cesarean section. Informed consent and creating a rapport with the mother is an essential aspect of safe and successful labor.

Contraindications

Vaginal delivery of face presentation is contraindicated if the mentum is lying posteriorly or is in a transverse position. In such a scenario, the fetal brow is pressing against the maternal symphysis pubis, and the short fetal neck, which is already maximally extended, cannot span the surface of the maternal sacrum. In this position, the diameter of the head is larger than the maternal pelvis, and it cannot descend through the birth canal. Therefore the cesarean section is recommended as the safest mode of delivery for mentum posterior face presentations.

Attempts to manually convert face presentation to vertex, manual or forceps rotation of the persistent posterior chin to anterior are contraindicated as they can be dangerous.

Persistent brow presentation itself is a contraindication for vaginal delivery unless the fetus is significantly small or the maternal pelvis is large.

Continuous electronic fetal heart rate monitoring is recommended for face and brow presentations, as heart rate abnormalities are common in these scenarios. One study found that only 14% of the cases with face presentation had no abnormal traces on the cardiotocograph. [8] It is advised to use external transducer devices to prevent damage to the eyes. When internal monitoring is inevitable, it is suggested to place monitoring devices on bony parts carefully.

People who are usually involved in the delivery of face/ brow presentation are:

Experienced midwife, preferably looking after laboring woman 1:1
Senior obstetrician
Neonatal team - in case of need for resuscitation
Anesthetic team - to provide necessary pain control (e.g., epidural)
Theatre team - in case of failure to progress and an emergency cesarean section will be required.
Preparation

No specific preparation is required for face or brow presentation. However, it is essential to discuss the labor options with the mother and birthing partner and inform members of the neonatal, anesthetic, and theatre co-ordinating teams.

Technique or Treatment

Mechanism of Labor in Face Presentation

During contractions, the pressure exerted by the fundus of the uterus on the fetus and pressure of amniotic fluid initiate descent. During this descent, the fetal neck extends instead of flexing. The internal rotation determines the outcome of delivery, if the fetal chin rotates posteriorly, vaginal delivery would not be possible, and cesarean section is permitted. The approach towards mentum-posterior delivery should be individualized, as the cases are rare. Expectant management is acceptable in multiparous women with small fetuses, as a spontaneous mentum-anterior rotation can occur. However, there should be a low threshold for cesarean section in primigravida women or women with large fetuses.

When the fetal chin is rotated towards maternal symphysis pubis as described as mentum-anterior; in these cases further descend through the vaginal canal continues with approximately 73% cases deliver spontaneously. [9] Fetal mentum presses on the maternal symphysis pubis, and the head is delivered by flexion. The occiput is pointing towards the maternal back, and external rotation happens. Shoulders are delivered in the same manner as in vertex delivery.

Mechanism of Labor in Brow Presentation

As this presentation is considered unstable, it is usually converted into a face or an occiput presentation. Due to the cephalic diameter being wider than the maternal pelvis, the fetal head cannot engage; thus, brow delivery cannot take place. Unless the fetus is small or the pelvis is very wide, the prognosis for vaginal delivery is poor. With persistent brow presentation, a cesarean section is required for safe delivery.

Complications

As the cesarean section is becoming a more accessible mode of delivery in malpresentations, the incidence of maternal and fetal morbidity and mortality during face presentation has dropped significantly. [10]

However, there are still some complications associated with the nature of labor in face presentation. Due to the fetal head position, it is more challenging for the head to engage in the birth canal and descend, resulting in prolonged labor.

Prolonged labor itself can provoke foetal distress and arrhythmias. If the labor arrests or signs of fetal distress appear on CTG, the recommended next step in management is an emergency cesarean section, which in itself carries a myriad of operative and post-operative complications.

Finally, due to the nature of the fetal position and prolonged duration of labor in face presentation, neonates develop significant edema of the skull and face. Swelling of the fetal airway may also be present, resulting in respiratory distress after birth and possible intubation.

Clinical Significance

During vertex presentation, the fetal head flexes, bringing the chin to the chest, forming the smallest possible fetal head diameter, measuring approximately 9.5cm. With face and brow presentation, the neck hyperextends, resulting in greater cephalic diameters. As a result, the fetal head will engage later, and labor will progress more slowly. Failure to progress in labor is also more common in both presentations compared to vertex presentation.

Furthermore, when the fetal chin is in a posterior position, this prevents further flexion of the fetal neck, as browns are pressing on the symphysis pubis. As a result, descend through the birth canal is impossible. Such presentation is considered undeliverable vaginally and requires an emergency cesarean section.

Manual attempts to change face presentation to vertex, manual or forceps rotation to mentum anterior are considered dangerous and are discouraged.

Enhancing Healthcare Team Outcomes

A multidisciplinary team of healthcare experts supports the woman and her child during labor and the perinatal period. For a face or brow presentation to be appropriately diagnosed, an experienced midwife and obstetrician must be involved in the vaginal examination and labor monitoring. As fetal anomalies, such as anencephaly or goiter, can contribute to face presentation, sonographers experienced in antenatal scanning should also be involved in the care. It is advised to inform the anesthetic and neonatal teams in advance of the possible need for emergency cesarean section and resuscitation of the neonate. [11] [12]

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Disclosure: Julija Makajeva declares no relevant financial relationships with ineligible companies.

Disclosure: Mohsina Ashraf declares no relevant financial relationships with ineligible companies.

This book is distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International (CC BY-NC-ND 4.0) ( http://creativecommons.org/licenses/by-nc-nd/4.0/ ), which permits others to distribute the work, provided that the article is not altered or used commercially. You are not required to obtain permission to distribute this article, provided that you credit the author and journal.

Cite this Page Makajeva J, Ashraf M. Delivery, Face and Brow Presentation. [Updated 2023 Jan 9]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-.

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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.

Illustration of the head-down, face-up position

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.

Illustration of the frank breech position

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.

Illustration of a complete breech presentation

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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Delivery, Face Presentation, and Brow Presentation: Understanding Fetal Positions and Birth Scenarios

Introduction:.

During childbirth, the position of the baby plays a significant role in the delivery process. While the most common fetal presentation is the head-down position (vertex presentation), variations can occur, such as face presentation and brow presentation. This comprehensive article aims to provide a thorough understanding of delivery, face presentation, and brow presentation, including their definitions, causes, complications, and management approaches.

Delivery Process:

Normal Vertex Presentation: In a typical delivery, the baby is positioned head-down, with the back of the head (occiput) leading the way through the birth canal.
Engagement and Descent: Prior to delivery, the baby's head engages in the pelvis and gradually descends, preparing for birth.
Cardinal Movements: The baby undergoes a series of cardinal movements, including flexion, internal rotation, extension, external rotation, and restitution, which facilitate the passage through the birth canal.

Face Presentation:

Definition: Face presentation occurs when the baby's face is positioned to lead the way through the birth canal instead of the vertex (head).
Causes: Face presentation can occur due to factors such as abnormal fetal positioning, multiple pregnancies, uterine abnormalities, or maternal pelvic anatomy.
Complications: Face presentation is associated with an increased risk of prolonged labor, difficulties in delivery, increased fetal malposition, birth injuries, and the need for instrumental delivery.
Management: The management of face presentation depends on several factors, including the progression of labor, the size of the baby, and the expertise of the healthcare provider. Options may include closely monitoring the progress of labor, attempting a vaginal delivery with careful maneuvers, or considering a cesarean section if complications arise.

Brow Presentation:

Definition: Brow presentation occurs when the baby's head is partially extended, causing the brow (forehead) to lead the way through the birth canal.
Causes: Brow presentation may result from abnormal fetal positioning, poor engagement of the fetal head, or other factors that prevent full flexion or extension.
Complications: Brow presentation is associated with a higher risk of prolonged labor, difficulty in descent, increased chances of fetal head entrapment, birth injuries, and the potential need for instrumental delivery or cesarean section.
Management: The management of brow presentation depends on various factors, such as cervical dilation, progress of labor, fetal size, and the presence of complications. Close monitoring, expert assessment, and a multidisciplinary approach may be necessary to determine the safest delivery method, which can include vaginal delivery with careful maneuvers, instrumental assistance, or cesarean section if warranted.

Delivery Techniques and Intervention:

Obstetric Maneuvers: In certain situations, skilled healthcare providers may use obstetric maneuvers, such as manual rotation or the use of forceps or vacuum extraction, to facilitate delivery, reposition the baby, or prevent complications.
Cesarean Section: In cases where vaginal delivery is not possible or poses risks to the mother or baby, a cesarean section may be performed to ensure a safe delivery.

Conclusion:

Delivery, face presentation, and brow presentation are important aspects of childbirth that require careful management and consideration. Understanding the definitions, causes, complications, and appropriate management approaches associated with these fetal positions can help healthcare providers ensure safe and successful deliveries. Individualized care, close monitoring, and multidisciplinary collaboration are crucial in optimizing maternal and fetal outcomes during these unique delivery scenarios.

Hashtags: #Delivery #FacePresentation #BrowPresentation #Childbirth #ObstetricDelivery

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

Variations in Fetal Position and Presentation |

During pregnancy, the fetus can be positioned in many different ways inside the mother's uterus. The fetus may be head up or down or facing the mother's back or front. At first, the fetus can move around easily or shift position as the mother moves. Toward the end of the pregnancy the fetus is larger, has less room to move, and stays in one position. How the fetus is positioned has an important effect on delivery and, for certain positions, a cesarean delivery is necessary. There are medical terms that describe precisely how the fetus is positioned, and identifying the fetal position helps doctors to anticipate potential difficulties during labor and delivery.

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

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

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

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

Head first (called vertex or cephalic presentation)

Facing backward (occiput anterior position)

Spine parallel to mother's spine (longitudinal lie)

Neck bent forward with chin tucked

Arms folded across the chest

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

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

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

The uterus is abnormally shaped or contains growths such as fibroids .

The fetus has a birth defect .

There is more than one fetus (multiple gestation).

Position and Presentation of the Fetus

Variations in fetal position and presentation.

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

Occiput posterior position

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

When a fetus faces up, the neck is often straightened rather than bent,which requires more room for the head to pass through the birth canal. Delivery assisted by a vacuum device or forceps or cesarean delivery may be necessary.

Breech presentation

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

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

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

In a first delivery, these problems may occur more frequently because a woman’s tissues have not been stretched by previous deliveries. Because of risk of injury or even death to the baby, cesarean delivery is preferred when the fetus is in breech presentation, unless the doctor is very experienced with and skilled at delivering breech babies or there is not an adequate facility or equipment to safely perform a cesarean delivery.

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

Labor starts too soon (preterm labor).

The uterus is abnormally shaped or contains abnormal growths such as fibroids .

My Sinciput (or Military) Position Birth Story, and How a Dream Helped me Through it

I can hardly believe my firstborn is five years old!

In honor of his birth, and in honor of women all over the world and through time who have had challenging labors and births, I am sharing Wolfgang’s birth story.

I also write this in honor of the wisdom of pregnant people and birthing people. At this time in the US, the way that the obstetrical medical culture is constructed often undermines the innate knowing of birthing people. Or at the least, we have lost some to the once-natural means to feel empowered as birthers. Our own guidance often takes the back seat to what medical experts or the mainstream pregnant and new parent culture readily feeds us.

We as birthers know much more than we are given credit. We are resourced from inside of our very selves. There in our blood, marrow and DNA are the stores of accumulated wisdom from the 2 million years of humans birthing.

A piece of guidance like a dream can be as helpful if not more helpful than any test of outsider giving advice. In some cases our own guidance is MUCH more valid because, let’s face it, the outcomes of obstetrics are not great right now, particularly so for people of color. In 2011 it was estimated that only 12% of obstetric practices was evidence based, making pregnancy, birthing and caring for newborns the area of healthcare with the least supported by evidence.

Wolfie was in what is called sinciput or military fetal position during labor and birth. In this position, the baby’s chin does not tuck to the chest as normal, and so the widest and hardest part of the top of the head enters the birth canal. When the craino bones line up this was instead of the intended way, it takes a long time for the head to mold or change shape. The mother/birther’s pelvis needs to open more widely than normal, to 11.5 cm or 11.75 cm instead of 10cm.

It is a seemingly relatively rare experience, and in five years of scouring the interwebs for more information about this malposition, I have found only two actual birth stories. So I am adding one more story in the mix, in the case that it might be helpful to someone.

The first sinciput birth story I read was one that I can no longer find on the internet, but it was similar to mine: a homebirth with long pushing, pain, caput, and need for extra recovery time afterwards.

The second story is a case report from a 1902 medical writings in which the doctors tried in vain to move the infant in utero to get it out of the sinciput position; sadly the birth resulted in a stillbirth.

I asked Gail Tully, midwife and fetal positioning expert of Spinning Babies, who was also my doula trainer in Minnesota, about sinciput births. She said it’s not as rare as one might think, and in the hospital it will just be a Caesarean and thus not potentially recognized or counted as being sinciput at all.

The interesting thing to me about this birth is that it was predetermined. A month or so before Wolife was born, I had a dream that foreshadowed his birth, and I was given specific instructions as how to get him earthside (which I speak about at the end of this blog entry).

Water Breaking

One Friday evening in December, another pregnant friend and I got together for dinner and hanging out at her place. We stayed up waaaay two late for two pregnant ladies, but it was fun and much needed.

I got home around 12:30 am. Rob, my husband was still up, we snuggled on the couch while watching a documentary about Fleetwood Mac (I am laughing because as I do one last read through before publishing, Fleetwood Mac is playing in the background of the coffee shop where I am working. From “Dreams”: Now here I go again / I see the crystal visions / I keep my visions to myself / It’s only me who wants to wrap around your dreams ). Around 1am, my water broke with a big gush.

I had been a birth doula for about 9 years, and I had learned that rarely does the water break in a huge gush like a comical movie. But mine did.

I didn’t have have any contractions, but I felt a distinct hormonal shift. Rob and I got as much ready as we needed to prep for impending birth at our house for about an hour before going to sleep.

We were lucky to have been as prepared as we were, because it was 11 days before the guess date/due date. In fact, I assumed that I would be 10 days past my due date, as first-time, white moms in their 30’s often were. As a doula I saw so many moms/birthers feeling sure were going to be early, then impatiently wait around another 15-20 more days.

The last thing I did before going to sleep was to collect myself. I looked at my face in the bathroom mirror. My pupils were dilated and bright. As I stared into my own eyes, I saw the wildness of birth breathing through me.

I would forever be changed, and this was the crossing the threshold journey of birth. It was the last time I’d be looking at my maiden self.

Early Labor

I woke around 6am with contractions. I floated in and out of sleep for as long as I could, and around 7am I had to raise and move around as the contractions were getting stronger, and I wanted to eat and drink while I still had an appetite.

That morning the doulas came. Labor progressed.

Early evening the midwives came. Still, progression.

In the evening, things picked up and the pain increased.

The first sign of things being a little different came to mind at this time. I had worse pain in between contractions than I did during them, right along the left pubic bone. I felt as if the baby was in a weird position, hung up on something. I didn’t think it was back labor, having seen that as a doula in the past. But it was something odd.

The pain in-between contractions made it challenging to relax or clear off the discomfort of the contractions. It was bothersome, and it was also easy to be swept up in the labor process and follow my instincts.

It was painful, but what could I do? I noticed it was odd, and I was also not bothered by it. It just was.

Pushing Part 1

My body began getting that pushy feeling around 8:30pm. In unmedicated, undirected labors, it is more noticeable that the mothers/birthers body begins pushing when it’s ready. The mom/birther sounds and looks “pushy”.

After 2 -3 hours of pushing, the midwives decided to “check”, or examine the cervix. Often in home births, the mother/birther is not checked. But after pushing this long, they had expected the baby to be born. An investigation was needed.

If the midwives were feeling “oh no”, they hid it well. I think they checked me, let me push for a while and check again, to see what was going on. They then checked me during a contraction (“checking” also included seeing the babies head position and how far down in the pelvis the baby has descended).

The midwives explained that the baby was in a funky position and needed some extra time for the head to mold as it came out.

We had a house wide lights-out rest time, possibly for about 60 – 90 mins. I was told not to push, rest as much as humanly possible, let the contractions wash over me.

It was during this time, when everyone was resting and I was enveloped in darkness of 3am in December, that I stepped into a birth energy that was revealed to me in a dream a few weeks prior. This was pivotal in helping Wolfie and I birth him into the world (I will tell that story later in this post).

Pushing Part 2

After the rest, we all had a renewed sense of possibility. But as is normal for labor, when things progress they often get more uncomfortable.

The experience of being in intense pain in between contractions heightened. This pain made me doubt myself and my ability to birth, because I couldn’t push past it – literally.

I recall being in the bathroom thinking I must go to the hospital and get an epidural or cesarean. The midwives didn’t think that was a good idea, or even possible. The baby was already engaged. We had to see it to the end. We were doing well, it was just long and painful.

The pain of that spot was really hard to handle. To this one of the midwives said something that has stuck with me ever since:

Find the exact location of the most intense pain and put all of yourself focus into that spot. Then push into that space with more strength then the pain, like its a keyhole you must get through.

Well, it was still incredibly hard to feel into that painful spot, let alone push into it. But with this directive and guidance to support me, I tired my very best.

Because of the babies head position, the midwives thought it would be best for me to push on my back with my knees bent. I tried and tried, for well over an hour.

The pressure was on. Everyone wanted — needed— this baby to be born soon.

One doula said in my ear, in the sweetest, softest more uplifting way humanly possible: “you need to push even harder, you need to go even farther now, farther than you ever thought was possible”.

The other doula kept bringing me honey on a spoon and bringing water to my lips. I hated this (oh, birthers do weird things, as if being in labor was any better). I tried to deny it, because I felt they both gave me headaches. Eventually she was like, “you need to eat this now. Your uterus needs this energy right this very instant. Accept it.”

The Final Pushes

I had done over 9 hours of pushing. Everyone was ready for this baby to be born.

One of the midwives had a new pushing idea that required a full-on team effort: I start pushing during a contraction on my back, holding knees or feet, then my team helped to lift me into a squat. Because of the baby’s position, a dual pushing approach might be good.

I had tried squatting, but for some reason at the very onset of pushing/contraction squatting wasn’t working well.

This new idea was crazy, and….drumroll…it worked!

After a few pushes like this, little Baby was born.

The Third Stage

I laid back on the pillows in my bed and took a couple of breaths. The midwives had to spend more time than normal checking out Baby. Baby was very blood and scratched, and they had to clean and investigate the severity of the wounds (which were minimal).

This took probably less than a minuet, him laying between my knees, being wiped and investigated. Much much less than in a hospital birth, but in home births the mom/birther can catch her/their own baby and and hold them immediately, minimal cleaning or investigating required.

Then we met, I held my little one and fell in love. Despite the effortful labor, I had the benefit of hormones of giving me energy, clarity, and mostly love and a deep sense of rightness.

Rob cut the cord when it had stopped pulsing and turned white. The placenta was delivered in its entirety and sent home with one of the midwives to encapsulate.

While the midwives were still at our home, I had a moment where I drifted off to sleep or a waking dream space. I wondered, “who is this little person?”, and as I closed my eyes I saw an image of a very beautiful German Shepard, who turned to look at me deeply in the eyes.

That sealed the deal about his name: Wolfgang, because it’s German and is associated with a dog. Rob and I are both German, and we wanted something to honor our ancestry. Gang means path or way in German: path of the Wolf.

When I was pregnant I had a dream in which one of my most important helping spirits came to me in a dream, one who I’ve met only once. She first came in a time of intense health and spiritual crisis. I dreamed I was enveloped in a great womb, and felt immense love and security. I looked up and saw her, she said her name was Celia too, and she is here to guide me. She was really the only light in the dark during that time of crisis.

In the pregnancy dream with her, I laid in her lap and she stroked my hair. She told me, “Don’t worry about him. He’s fine. Gabriel is fine.” She was referring to the baby, of course.

Yes, Wolfie’s name was almost officially Gabriel, but in the end we couldn’t agree on it. We talk about it often and say it is his “womb name” or “Angel name”, and he steps into that name often. When Wolife was three he said for along time that his full name was “Wolfgang John Robin Red Breast Gabriel Linnemann”.

I will definitely continue to honor this womb name of his. When I was in the womb, my mom had a dream in which little red fairies came in the room and danced around her belly, and she was told that “Your baby is an angel, name her Celia”.

Early Postpartum

Early postpartum was rough for me.

After becoming a mother myself, I now see how the early postpartum period is the most overlooked and under-supported part of becoming a mother/parent. I hope we can collectively talk about it more, and create deeper support systems for one another.

Because of his rough birth, Wolfie didn’t have a suck reflex and couldn’t latch on until 14 hours after his birth, which is when a neighbor who was a lactation consultant randomly bumped into Rob while he was taking out the garbage. She volunteered to come over, and I am so glad she did. She worked on his mouth for a long time, and then finally the suck reflex was triggered.

The best thing my dear, dear friend Sarah Jane helped me with is to show me how to hand express milk (hand expression is such a critical skill but we aren’t shown how to do it properly. Bonus: if you learn hand expression you never need to be at the whim of the pump!). At that point, just a few drops of colostrum came out.

I have to take a moment to share my awe about colostrum. To me it is like the mammalian gift. The colostrum was simply gorgeous. On one side of my nipple, reddish brown colostrum would come out, and on the other side (of the same nipple, mind you), caramel colored came out. They swirled together into one shimmery bead, looking like a cosmic Yin-Yang symbol sitting on my fingertip. I tried a drop when I could, how could I let any of it go to waste? It was delicious – definitely caramel creamy. It’s no wonder we go crazy over things like ice cream and caramel topping. Yes, the birth h

When Wolfie was too tired to nurse properly, I would squeeze some onto my pinky finger tip and Wolfie would suck on my finger. With the hand expression I never had to worry that a) my milk wasn’t coming out and thus impacting my supply, b) even if he couldn’t latch, he could still be fed and c) I didn’t need to mess with a pump. The next day I had more colostrum, enough to fill a small spoon, which I could place at his lips and he would suck or drink.

I am sooooooooo thankful of her help and guidance. In so many ways, she helped save our entire nursing relationship and my milk supply. Possibly even more – what if he never really latched on until the midwives arrived the next day? He would try to latch on, but since I was new to this, I didn’t really understand what he was or was not actually getting as a result of that latching. The midwives also trusted me more than usual, because I had been a birth doula and had so called experience with early nursing. During my pregnancy I had even taken a breastfeeding course for my doula education.

Even after he started to latch on successfully, it was obvious something was wrong. My nipples were very sore and both were cracked and bleeding. Sarah Jane suspected a posterior lounge tie, and had her supervisor come over to confirm. Yes, it was a tongue tie.

In that first week, each nursing brought me to tears or nearly tears. The pain was over the top for me.

At the time, I said I’d rather push him out again for 9 1/2 hours than have to feel the pain on nursing. I acknowledge that it was indeed painful. I also acknowledge that it is really easy to feel overwhelmed when things go wrong in that first week.

My midwife was an experienced herbalist and gave me some Motherwort – it works so well in postpartum stress. I added in Skullcap and Ashwaganda. That triad held my hand during early postpartum. In later weeks I added in White Peony, another motherly plant to pain with Motherwort, and to worked well in keeping me calm and soothed.

Wolife had a laser surgery for tongue tie when he was 8 days old. Lo and behold, the leading tongue tie ENT doctor in the world works and practices in Portland. I am grateful for this and truly hope that more people across the country can have access to this level of care before too long. One reason I love Portland is because this is truly a place of pioneering health care in all realms.

Luckily for us, he was getting a ton of milk. So many of the mom’s in the breastfeeding support groups who had the tongue tie also dealt with the baby not getting enough milk due to the disfunction latch, which would result in the vicious cycle of reducing milk supply.

It took many weeks to have painless nursing. But eventually we got there.

I was also so so lucky to be able to have a cranio-sacral therapist come to my home to work on Wolife. There are (no surprise) many wonderful CST who are highly trained in infants with tongue ties. She knew just what to do to help his tongue and palate and nervous system heal and grow strong.

Recovery was also really rough because I fractured my tailbone during the birth. My wise and adaptable body made as much room as possible! Sitting on a broken tailbone and nursing with cracked and bleeding nipples – oh, it was uncomfortable. The best advice I had was to take it one feeding at a time. Stay in the present moment. It helped.

Both Wolfie and I had slices of flesh taken off of us during the birth, probably when we was hung up on the bones and we just had to push through it. He had wounds on his head, and I had them in my pelvis. He needed that much more space. They were surface wounds, no stitches needed. But it added to the discomfort.

Yarrow and Uvs Ursi sitz baths helped — I reserved a little bit of the bath to dab on his head wounds— but mostly he and I just needed time.

Moxa helped too. My dear friend Alison came over and did moxa to my uterus and tailbone…it was amazing.

Dream Instructions

Before Wolfie was born, I had a dream that gave me specific instructions as how to birth him. I realized during part of the pushing, “Hey! This waterfall feeling is straight from that dream, and I think it’s key in getting this baby born!”. At the time of the dream, I knew it was a powerful dream and it had immense meaning. It had that alive feeling: weighted and electric. But I didn’t put two and two together until I was in the middle of labor.

I dreamed I was floating down a lazy river, head first.

Suddenly I came to rocky rapid and my head got caught between two rocks. In a split second I thought, “This is it! I’m going to drown!”. The water rushed over my head and I couldn’t breathe.

A powerful presence arrived. It felt like the air ripe with a tornado or lightning, and it felt big. It came from the water flowing over the rocks, and they talked to me. They said “don’t worry about breathing, drink from the air pockets held in the water rushing over your face”. I was apprehensive but I did just that: I started to breath in as the water was flowing over my face, and I found air like they said I would.

I rested there for a while, somehow drinking air from the water. I became impatient and worried and asked, “what am I supposed to do now?” I couldn’t live here forever, being underwater with my head stuck between rocks.

A powerful feeling welled up from the force of the water flowing over the rocks. It built and built. It became as strong as the flow of the huge waterfall, and it crashed down around me. This waterfall feeling shook me loose from the rocks. I saw that it would only loosen me if I completely surrendered and relaxed.

After sometime, the waterfall pushed me out to the clear side of the rapids, and I was once again floating down the lazy river, head first.

This situation repeated again and again: I floated down the river, my head became stuck between rocks, I drank from air pockets while underwater, then the waterfall force would build strong until, when in complete surrender, It shook me loose from the rocks.

Once I recognized the feeling of the waterfall during pushing, I had to follow it’s instructions. There was no doubt in my being.

There were times when I had a contraction but the waterfall force wasn’t there, so I didn’t push. Sometimes I had a waterfall force but did not have a contraction, but I was compelled to push.

This was my own guidance that I felt compelled to follow. At times it went against the midwives instructions, but I had to follow it. This force flowed until it flowed out my baby.

Guidance at a Home Birth

The last birth I had attended as a doula was the birth of a dear friend’s baby. Her baby was quite stuck: a real case of shoulder dystocia and almost an emergency situation. I saw during that home birth that a third party guide that can become a real player in the birth outcome.

I also saw that although contractions are a powerful bodily force, they not the only way to get a baby out. My friend was compelled to push and push and push at the end, for what felt like minutes on end, regardless of contractions. That’s how her baby was born.

Contractions are functional and for a reason, but other, invisible forces can be just as real.

During Alison’s birth, in the middle of a house-wide rest in the dark after a couple hours of pushing, I entered a waking-dream/journey space and called for help but saw that help was already there. It looked like it was doing some sort of medical Qi Gong on the mom and baby. My friend Alison and I met in Chinese medicine school, so this kind of cosmology felt natural.

Once I felt the presence of a greater spiritual force, I held it in my mind and body. When her baby came out, blue and not breathing, midwives talking very loudly (aka yelling), getting oxygen ready and about to call the paramedics, I could see how my friend and her baby were connected to a greater golden thread of support.

One midwife said in a composed panic, while running the sharp tip of her fingernail up the baby’s spine to arouse it, yelled/said, “Talk to your baby! Talk to your baby, now!”. Mama said, “hello, welcome, I love you”, in the most reassuring, calm and natural of voices.

Not a quiver of fear.

As she started to speak, I touched her left forearm and saw liquid gold flow from my palm from the heavens into her veins, through her body and out her other hand that stroked her infant. I will never forget Alison, like some sort of fiery Goddess, with the golden veins, just having squatted out her baby. He breathed and in that instant it was assured everything was OKAY.

When it was my turn to look for midwives I instantly thought of those at Alison’s shoulder dystocia birth. I knew those were tricky births, often (excuse the violent language, but it represents the truth) mangled in the hospital. They require a high level of skill. The midwives were also really kind to me, which I noted because doulas are sometimes flies on the wall, and not paid attention to. A few days after, they called me and checked in, and said they were there if I had any questions. A complicated birth can carry more potential for vicarious trauma for the birth workers, and they were very helpful in providing trauma-reduction.

As for my doulas, I asked them that if it felt needed, would they pray for me? Would they journey for me? Would they hold faith against all odds? They agreed. I think they did during the birth, in their own way. They said as much. That meant the world to me.

Thinking back even further, I can’t help but wonder if I was set up to attend home births and home births only when I moved to Portland. I tried to make it as a doula here, after getting a number of births under my belt in Minnesota. But I was turned down for every hospital birth that I interviewed for. After 10 or so rejections, I thought maybe I wasn’t meant to be a doula.

I did, however, have the wonderful opportunity to attend 6 home births in a row. After 3 home births, I kind of “got” it. I saw how different home births were than hospital births. Someday I’ll go into that, but the most marked difference, beside just the comfort factor, was that the mother/birther and baby were trusted to take their course as they may. The birthing wisdom was honored.

As I see it now, with new eyes, perhaps it was important for me to be guided into the home birth direction. I have been a part of the birth doula community in Portland for 9 years at the time of writing this. Just recently I was talking to some birth doulas at the monthly doula organization gathering about home births, and they all were mystified. None in that group had ever attended a home birth, not even the busiest, most long term doulas. It’s not typical that home birthers use doulas here.

How did I end up attending those home births? I didn’t advertise or seek them in the slightest, they just fell into my lap. I was, however, really really working hard to attend hospital births, but despite my determination, it never worked out.

Why was this predetermined? Will I ever know? Probably not. But I do think some things in our lives are set up for us, so why would birth be any different?

And was our birth process because Wolife had to be born this way, or because I had to birth this way, or both? Or neither?

This birth expense is deeply connected to me, for sure. Years later when I was working directly with ancestors (who, interestingly, came during a re-birthing experience) I found that an ancestral helping spirit was water flowing over rocks. I was happy and very thankful to know that they were they ones who showed me how to birth Wolife.

Step by step, I am starting to unravel this story. All these parts of our lives are the fibers that weave through this existence and beyond.

It is a little nerve wracking to speak openly about the “out-there” and spiritual sides of this birth. But A) everyone already knows I’m “weird”, so no shocker there. And B) if everyone else started talking about the odd coincidence of their own birth stories, we’d see that this is indeed commonplace.

Dreams are part of our ability to survive. They seem otherworldly and spiritual – and they are – but they are mostly mundane and simply giving help.

Thanks for listening.

Much love and blessings,

Email for the journey

Military Obstetrics & Gynecology – 3rd Edition

Breech delivery.

Breech delivery is the single most common abnormal presentation.

The incidence is highly dependent on the gestational age. At 20 weeks, about one in four pregnancies are breech presentation. By full term, the incidence is about 4%.

Other contributing factors include:

Abnormal shape of the pelvis, uterus, or abdominal wall,
Anatomical malformation of the fetus,
Functional abnormality of the fetus, and
Excessive amniotic fluid (polyhydramnios).

Types of Breech Presentation

Breech babies can present in a variety of ways, including buttocks first, one leg first or both legs first.

Frank breech means the buttocks are presenting and the legs are up along the fetal chest. The fetal feet are next to the fetal face. This is the safest arrangement for breech delivery.

Footling breech means either one foot (“Single Footling”) or both feet (“Double Footling”) is presenting. This is also known as an incomplete breech.

Complete breech means the fetal thighs are flexed along the fetal abdomen, but the fetal shins and feet are tucked under the legs. The buttocks is presenting first, but the feet are very close. Sometimes during labor, a complete breech will shift to an incomplete breech if one or both of the feet extend below the fetal buttocks.

Risks of Vaginal Breech Delivery

While all vaginal breech deliveries involve some degree of increased risk, footling breech deliveries are the most dangerous. They are notably associated with an increased risk of:

Umbilical cord prolapse, and
Delivery of the feet through an incompletely dilated cervix, leading to arm or head entrapment.

In cephalic presentations, the head fits very well into the lower uterine segment and usually physically blocks the umbilical cord from falling out before the fetus. Umbilical cord prolapse occurs more frequently with breeches because the breech often does not fit as well into the lower uterine segment very well. The risk of prolapsed cord is somewhat increased for frank breech, increased more for complete breech, and significantly increased for footling breech.

Head entrapment occurs when the smaller body of the fetus passes through the cervix before it is completely dilated, leaving the larger fetal head trapped behind an incompletely dilated cervix. This can be a big problem, since the umbilical cord is usually occluded at that point by the head wedged into the lower uterine segment. It is more likely to occur the more premature the fetus. Younger fetuses tend to have larger heads in proportion to their torsos. At 36 weeks, the heads and torsos are approximately the same size. After 36 weeks, the proportions steadily reverse and by full term, the fetal heads are smaller than the fetal torso.

In general, vaginal breech delivery poses more risks for the fetus than cesarean section. These risks include both asphyxial injury and mechanical injury to the fetus as it is delivered. Because of these risks, some physicians deliver most or all their breech babies a by cesarean section. Other physicians will attempt vaginal breech delivery if:

He/she is experienced with vaginal breech deliveries and their complications,
The overall risk environment is low, and
The informed mother desires this over cesarean section.

It’s difficult to quantify how much experience and how current that breech experience should be. Many well-trained obstetricians will deliver 100 babies a year. Of those, about 4 of them will be breech. Half of those will likely be delivered by cesarean section because of high-risk factors. One more will probably be delivered by cesarean because the mother prefers cesarean delivery. For this initially well-trained obstetrician, continuing vaginal breech delivery experience may only occur once a year. It may prove difficult for that obstetrician’s skills to remain current under these circumstances.

Risk Factors

Factors that are often considered when contemplating a vaginal breech delivery include:

Size of the fetus (not too small and not too large)
Size of the maternal pelvis (the larger the better)
Previous vaginal births (more is better)
Previous vaginal breeches (more is better)
Gestational age (not too old and not too young)
Presentation (Frank breech is best, but complete breech is better than footling breech)

Electronic fetal monitor tracing of labor (normal is good, non-reassuring is bad).
Progress in labor (normal progress is good, slow progress is bad)
Availability of resources (immediate presence of anesthesia, OR, nursing, pediatrics, etc. is good, possibly delayed is bad)
Enthusiasm of the informed mother for vaginal breech (very enthusiastic is good, not so enthusiastic is bad)

Spontaneous Breech Delivery

The simplest breech delivery is called a spontaneous breech.

The mother pushes the baby out with the normal bearing down efforts and the baby is simply supported until it is completely free of the birth canal. These babies pretty much deliver themselves.

This works best with smaller babies, mothers who have delivered in the past, and frank breech presentation.

Assisted Breech Delivery

If the breech baby gets stuck half-way out, or if there is a need to speed the delivery, an “assisted breech” delivery may be necessary. For this type of delivery, it is very helpful to have:

At least one qualified assistant,
An anesthetist or anesthesiologist in the event general anesthesia is needed, and
Someone skilled in neonatal resuscitation other than yourself.

The wisest of obstetricians has these individuals present for all breech deliveries.

Make sure you have a generous episiotomy. This will give you more room to work, but may be unnecessary if the vulva is very stretchy and compliant. Otherwise, you can make an episiotomy, enlarge a pre-existing episiotomy, surgically (with scissors) extend a pre-existing perineal laceration, or make a second episiotomy. Some physicians will intentionally extend an episiotomy into the rectum (“proctoepisiorrhaphy”) because it gives them lots of room, is relatively easy to repair after the delivery, and rarely leads to any long-term problems for the mother.

Grasp the baby so that your thumbs are over the baby’s hips. If you grasp the baby any higher than that, there is some risk of injury to the fetal kidneys and abdominal organs.

If the baby is not facing “face down,” gently rotate the torso so the baby is face down in the birth canal (facing toward the maternal recutm).

Wrap a towel around the hips and legs. It will provide a more secure grip and will keep the legs secure and out of the way.

Have your assistant apply suprapubic pressure to keep the fetal head flexed.

Exert gentle outward traction on the baby while rotating the baby first clockwise and then counterclockwise a few degrees to free up the arms.

If the arms are trapped in the birth canal, you may need to reach up along the side of the baby and sweep them, one at a time, across the chest and out of the vagina. (More on this later.)

Keep the baby at or below the horizontal

Keep the baby’s body at or below the horizontal plane or axis of the birth canal.

If you bring the baby’s body above the horizontal axis, you risk injuring the baby’s spine through hyperextension.

Only when the baby’s nose and mouth are visible at the introitus is it wise to bring the body up. At this point, you can visually see the attitude of the fetal head and avoid hyperextension.

Suprapubic pressure to keep the fetal head flexed

The application of suprapubic pressure by the assistant is important for keeping the head flexed against the chest, expediting delivery, and reducing the risk spinal injury.

At this stage, the baby is still unable to breath and the umbilical cord is likely occluded.

Without rushing, move steadily toward a prompt delivery.

Placing your finger in the baby’s mouth may help you control the delivery of the head.

Try not to let the head “pop” out of the birth canal. A slower, controlled delivery is less traumatic.

Entrapped Head

Sometimes, after delivery of the fetal torso and arms, the head remains trapped, unable to pass through the cervix. This is a problem that must be promptly resolved.

If the cervix is stretchy enough, increased pushing efforts by the mother and suprapubic pressure by an assistant can overcome mild head entrapment and lead to prompt delivery.

If the cervix is not stretchy enough, or there is more than mild degrees of head entrapment, it will be necessary to cut the cervix longitudinally (Dührson’s Incisions) to quickly enlarge the cervical opening before the fetus is compromised. After delivery, you can repair the cervix. The traditional recommendation for these incisions is at about 10 o’clock and 2 o’clock, but anywhere you can get enough exposure will likely work.

Nuchal Arms

Normally during a breech delivery, the fetal arms remain flexed across the chest and deliver with the fetal torso. Arm entrapment (nuchal arms) occurs when the arms become raised up over the fetal head. Not only must the head pass through the cervix, but the added bulk of one or two arms must come with it. If the cervix is stretchy enough, normal delivery may still occur spontaneously.

In other cases, you must:

Identify the shoulder blade
Follow the humerus as far up to the elbow as you
Flex the arm, sweeping the extended arm down, across the chest and out of the vagina.

If both arms are trapped, then you must perform this maneuver twice, once for each arm. There are dangers in performing this maneuver, of course. You may dislocate the fetal shoulder, or fracture the shoulder, collarbone, or humerus. Try to be gentle in performing this maneuver to avoid injury to the fetus. Remember, though, that failure to resolve this problem will result in fetal death, so it is important to use that degree of force necessary to deliver the fetus. Broken bones will heal.

Military Settings

In far forward military environments, it is good to remember that most breech babies can be safely delivered without any obstetrical intervention. With that principle in mind, be prepared to watch anxiously (and without pulling on anything) while the breech is delivered primarily through the expulsive efforts of the mother. If the breech becomes stuck, it is most likely due to the fetal arms extending over the head. In this case, follow the guidance above and sweep the arms down across the fetal chest. Then, using your hand over the pubic bone, exert suprapubic pressure to keep the fetal head flexed as it is pushed out from the birth canal.

Women's Healthcare in Operational Settings

Abnormal Fetal Position and Presentation

Under normal circumstances, a baby is in the vertex (cephalic) position before delivery. In the vertex position, the baby’s head is at the lower part of the abdomen, and the baby is born head-first. However, some babies present differently before delivery. In these cases, abnormal presentations may place the baby at risk of experiencing umbilical cord problems and/or a birth trauma (1). Types of abnormal fetal positions and presentations include the following. We’ll cover each in more detail on this page.

What is the difference between fetal presentation and position?

In the womb, a fetus has both a presentation and a position . Presentation refers to the baby’s body that leads, or is expected to lead, out of the birth canal (9). For example, if a baby’s rear is set to come out of the birth canal first, the baby is said to be in “breech presentation.” Position refers to the direction the baby is facing in relation to the mother’s spine (9). A baby could be lying face-first against a mother’s spine, or face up towards the mother’s belly.

What way should a baby come out during birth?

Vertex presentation is the ‘normal’ way that a baby is positioned for birth and the lowest-risk presentation for vaginal birth (1). 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 (2). If a baby’s chin isn’t tucked into their chest, they may come out face-first (face presentation), which can cause birth injury (1).

What happens if a baby isn’t in the standard 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 (1). 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 abnormal presentation.

Compound 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 (3).

Risk factors for compound presentation include (3):

Prematurity
Intrauterine growth restriction (IUGR)
Multiple gestations ( twins , triplets, etc.)
Polyhydramnios
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 a cervical examination (3).

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 (3). If compound presentation continues, it is likely to cause dystocia (the baby becoming stuck in the birth canal), which is also a medical emergency (3). 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) (3).

Limb presentation

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 cannot be delivered safely via vaginal delivery; they must be delivered quickly by emergency C-section (4). 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 19 babies present in a posterior position rather than an anterior position. This is called an occipitoposterior (OP) position or occiput posterior position (3) In OP position, the baby is head-first with the back part of the head turned towards the mother’s back, rotated to the right (right occipitoposterior position, or ROP), or to the left (left occipitoposterior position, or LOP) of the sacroiliac joint. Occipitoposterior position increases the baby’s risk of experiencing prolonged labor , prolapsed umbilical cord , and use of delivery instruments, such as forceps and vacuum extractors (5). These conditions can cause brain bleeds , a lack of oxygen to the brain, and birth asphyxia .

When OP position is present, if a manual rotation cannot be quickly and effectively performed in the face of fetal distress, the baby should be delivered via C-section (5). A C-section can help prevent oxygen deprivation caused by prolonged labor, umbilical cord prolapse, or forceps and vacuum extractor use.

A nurse explains posterior position

Breech presentation

Breech presentation is normal throughout pregnancy. However, by the 37th week, the baby should turn to the cephalic position in time for labor. Breech presentation occurs when a baby’s buttocks or legs are positioned to descend the birth canal first. Breech positions are dangerous because when vaginal delivery is attempted, a baby is at increased risk for prolapsed umbilical cord, traumatic head injury, spinal cord fracture, fatality, and other serious problems with labor (6).

There are 4 types of breech positions:

Footling breech presentation : In footling position, one or both feet enter the birth canal 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, the legs are flexed at the hip and extended at the knees, and the feet are 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 the feet beside the 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 ) (7). 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 (6). Mismanaged breech birth can result in the following conditions:

Brain bleeds, intracranial hemorrhages
Spinal cord fractures
Hypoxic-ischemic encephalopathy (HIE)
Cerebral palsy
Intellectual disabilities
Developmental delays

Face presentation

A face presentation occurs 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 the airway to maintain airway patency and assist breathing (1).

Image by healthhand.com

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 is very common during vaginal delivery of a baby in face presentation, so parents must be warned that their baby may be bruised and that a C-section is available to avoid this trauma.

Babies presenting face-first can sometimes be delivered vaginally, as long as the baby is in MA position (1). 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 (1). Babies in MP position must be delivered by C-section. Babies in MT position must also be delivered by C-section. Some babies in the MP and MT positions will spontaneously convert to the MA position during the course of labor, which makes vaginal delivery a possibility. If the baby is in the MA position and vaginal delivery is able to proceed, engagement of the presenting part of the baby probably will not occur until the face is at a +2 station (1).

The management of face presentation requires close observation of the progress of labor due to the high incidence of CPD with face presentation. 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 (1).

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 (1).

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. Outlet forceps should only be used by experienced physicians; these forceps increase the risk of trauma and brain bleeds. In almost all clinical circumstances a cesarean delivery is the safest method of delivery.

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
Permanent brain damage

Brow 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 backward. 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.

Risk factors and conditions associated with brow presentation

Brow presentation has been linked to several risk factors and co-occurring conditions. These include:

Multiparity (having previously given birth)
Premature delivery
Fetal anomalies such as anencephaly (an absence of major parts of the brain and skull) or anterior neck mass (a growth on the front of the neck)
Previous c-section delivery
Polyhydramnios (excessive amniotic fluid: infants swallow amniotic fluid while in utero, but this may be difficult if their neck is extended)

Diagnosis of brow presentation

Brow presentation can often be diagnosed through a vaginal examination during labor. If there are no conclusive signs from the physical examination alone, an ultrasound can also be used. Warning signs of brow presentation may include signs of fetal distress or lack of labor progression.

Management of brow presentation

Infants who assume a brow presentation early in labor may spontaneously move into a more optimal position during the delivery process. Additionally, safe delivery in brow presentation may be possible if the infant is unusually small and/or the mother’s pelvic opening is unusually large. For these reasons, physicians occasionally recommend vaginal delivery of infants in brow presentation.

Doctors attempting vaginal delivery of a baby in brow presentation must be very careful to watch for signs of fetal distress (such as an abnormal heart rate), and to monitor the progression of labor. Prolonged labor can cause extended periods of fetal oxygen deprivation, which can cause birth asphyxia and permanent injury. Signs of fetal distress can indicate that a baby is in danger of sustaining serious brain damage if action is not quickly taken to prevent this. If an infant in brow presentation begins to show signs of distress, or if labor progress stops or slows significantly, physicians should be ready to move on to a cesarean delivery.

Labor induction or augmentation with the drug Pitocin (synthetic oxytocin) is very dangerous in cases of brow presentation. Pitocin can lead to excessive uterine contractions, which can put pressure on the infant’s head and cut off their oxygen supply; this is especially risky when safe fetal descent is already compromised, such as in cases of brow presentation.

Complications of brow presentation

If brow presentation is diagnosed in a timely fashion and is appropriately managed, there are typically no serious negative effects on the mother or baby. However, if medical professionals fail to recognize brow presentation and intervene as necessary, there can be lasting consequences. Infants may suffer oxygen deprivation due to prolonged labor, or traumatic injuries from a difficult delivery. Some of the most severe conditions resulting from mismanaged brow presentation births include:

Hypoxic-ischemic encephalopathy
Periventricular leukomalacia
Seizure disorders
Developmental disabilities

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, C-section is almost always used as the delivery method (8). Mothers who have polyhydramnios (too much amniotic fluid), are pregnant with more than one baby, have placenta previa, or have a baby with intrauterine growth restriction (IUGR) are more likely to have a baby in the transverse lie position (8). 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 (8). 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

The award-winning birth injury attorneys at ABC Law Centers 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. During your free legal consultation, our birth injury attorneys will discuss your case with you, determine if negligence caused your loved one’s injuries, identify the negligent party, and discuss your legal options with you.

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Julien, S., and Galerneau, F. (2017). Face and brow presentations in labor. Retrieved from https://www.uptodate.com/contents/face-and-brow-presentations-in-labor .
World Health Organization, UNICEF, and United Nations Population Fund. Malpositions and malpresentations. Retrieved from http://hetv.org/resources/reproductive-health/impac/Symptoms/Malpositions__malpresetations_S69_S81.html .
Barth, W. (2016). Compound fetal presentation. Retrieved from https://www.uptodate.com/contents/compound-fetal-presentation .
Gabbe, S.G., … Grobman, W.A. (2017). Compound Presentation. Retrieved from https://expertconsult.inkling.com/read/gabbe-obstetrics-normal-problem-pregnancies-7e/chapter-17/compound-presentation .
Argani, C.H. and Satin, A.J. (2018) Occiput posterior position. Retrieved from https://www.uptodate.com/contents/occiput-posterior-position .
Hofmeyr, G.J. (2018). Overview of issues related to breech presentation. Retrieved from https://www.uptodate.com/contents/overview-of-issues-related-to-breech-presentation .
Hofmeyr, G.J. (2017). Delivery of the fetus in breech presentation. Retrieved from https://www.uptodate.com/contents/delivery-of-the-fetus-in-breech-presentation .
Strauss, R.A. (2017). Transverse fetal lie. Retrieved from https://www.uptodate.com/contents/transverse-fetal-lie .
Moldenhauer, J.S. (2018). Abnormal Position and Presentation of the Fetus. Retrieved from https://www.merckmanuals.com/home/women-s-health-issues/complications-of-labor-and-delivery/abnormal-position-and-presentation-of-the-fetus .

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Face Presentation Birth: Is it Dangerous?

Birth Injuries

The first thing everyone wants to see after a birth is a baby’s adorable face. But that’s not the first thing doctors should see when the child makes an entrance into the world. Arriving “face first” is called “face presentation birth”, and it can be dangerous.

In this article, we’ll discuss:

What is face presentation birth?
Is face presentation birth dangerous?
What are some complications from a face presentation birth?
What can you do if your doctor mismanages your face presentation birth and injures the child?
When can you take legal action , and how?

What is a Face Presentation Birth?

When we talk about “presentation”, we’re talking about how the baby positions itself in the womb as labor approaches. The part that faces downward will come through the birth canal first, whether it’s the head, the foot, or something else.

The most common and favorable presentation for vaginal birth is the vertex presentation. It’s also known as the “head-down” position.

But several other presentations can occur, including:

Breech . The baby’s buttocks or feet are positioned to come out first
Transverse . The baby lies horizontally across the uterus, with its shoulder or back presenting at the cervix .
Compound. The baby’s hand, arm, or another body part alongside the head presents at the cervix alongside the head.
Shoulder . The baby is sideways in the uterus. One shoulder presents at the cervix.
Face . The baby’s face is positioned to come out first.

Many of these presentations may require medical intervention or cesarean section delivery. Some can be dangerous for both mother and child–and the face-down position is one of them.

Is Face Presentation Birth Dangerous?

Yes, attempting a face presentation birth can be dangerous. Why? First of all, it means the baby’s head is pulled backward as it descends through the birth canal. You can imagine how uncomfortable this would be. In normal circumstances, a baby’s chin would point down at the chest.

But this position isn’t just uncomfortable for an infant. It’s risky, because the baby may get stuck while descending. It may also spell severe discomfort for the mother, who must endure long, difficult labor.

A face presentation birth can result in a host of birth injuries, such as:

Asphyxia (oxygen deprivation)
Trauma to the face and head
Spinal cord injuries
Fetal heart rate issues
Cerebral palsy and other brain injuries
Breathing problems (due to tracheal and laryngeal injuries)
Fetal distress
Facial bruising or swelling
Facial nerve injury
Soft tissue injuries
Prolonged labor
Maternal injuries

Baby faces challenges after difficult birth.

Face Presentation Causes & Risk Factors

These conditions may increase the likelihood of a face presentation birth:

A Very Big Baby (Fetal Macrosomia): Larger babies may have trouble fitting into the birth canal in the standard position, leading to alternative presentations.
Prematurity: Premature infants are more likely to have non-standard presentations, including face presentation, because of their small size and muscle tone.
A Very Low Birth Weight (VLBW ) : Similar to prematurity, lower birth weight can affect fetal position and presentation.
Maternal Obesity: Obesity can be associated with a variety of complications in pregnancy and childbirth, including potentially affecting fetal position.
Excessive Fetal Mobility: Sometimes, an unusually mobile fetus can adopt a face presentation position.
Anencephaly: This severe birth defect can alter the usual mechanics of labor and fetal positioning.
Anterior Neck Mass: This could cause the fetus to extend its neck, leading to a face presentation.
Mother Has Given Birth Multiple Times (Multiparity ) : In multiparous women, the uterine and pelvic muscles may be more relaxed, leading to a higher likelihood of non-standard presentations.
Excessive Amniotic Fluid (Polyhydramnios): Too much amniotic fluid can allow the baby more room to move, potentially leading to unusual positions.
Maternal Pelvis Abnormalities: Irregularities in the size or shape of the maternal pelvis can affect how the baby positions itself for birth.
Multiple Nuchal Cords: While not a necessarily direct cause, multiple loops of the umbilical cord around the baby’s neck can contribute to abnormal presentations.
CPD ( Cephalopelvic Disproportion): When the baby’s head is too large or the mother’s pelvis is too small for vaginal birth in the typical head-first position, it can lead to a face presentation position.

These are some of the conditions that can increase a mother’s chances of having a face presentation birth.

Diagnosing and Treating Face Presentation

When a woman goes into labor, doctors perform a vaginal examination to find out what position the baby is in. If they suspect it’s not head down, they should conduct an ultrasound.

The ultrasound makes confirming an abnormal presentation easy. It lets the medical team see exactly how the baby is lying in the womb. Isn’t modern medicine wonderful?

There’s just one problem: doctors can and do make mistakes. They can mismanage a face presentation birth and cause severe injuries.

For example, let’s say a physician conducts a physical examination only. They could confuse face presentation with breech. If they don’t go a step further and confirm with an ultrasound, they might make the wrong decision about how to proceed.

In most cases, a face presentation birth shouldn’t be attempted vaginally. A C-section is the safer alternative. But this depends on several factors, such as the type of face presentation. That’s what we’ll look at next.

Types of Face Presentation

These are the three main types of face presentation:

Mentum Anterior (Chin First) Presentation. The baby’s chin leads the way through the birth canal. The forehead is closest to the mother’s spine.
Mentum Posterior (Forehead First) Presentation. The baby’s forehead is positioned to come out first, with the chin closest to the mother’s spine.
Mentum Transverse (Face in Transverse Position) Presentation. The baby’s face turns sideways in the birth canal. In other words, the baby lies with the face parallel to the mother’s pelvis, rather than being aligned with the head-down or head-up positions.

A baby can be injured in any of these types of face presentation, and sometimes it’s due to negligence.

Closeup of baby's hand in NICU incubator.

Legal Help for Mismanaged Face Presentation Birth

Standard protocol for face presentation birth prohibits doctors from doing these things (in most cases):

Aggressive pushing or pulling maneuvers during delivery
Attempt to rotate the baby with their hands
Try to pull the baby out with their hands
Excessive manipulation of the baby’s head
Use forceps or a vacuum to pull the baby out.
Ignoring signs of fetal distress
Ignoring maternal discomfort or distress
Rushed delivery

These actions heighten the risk of causing irreversible trauma. If a doctor decides to act against protocol and causes an injury, it constitutes negligence. Patients may be able to sue for the cost of treatment for the injury.

Of course, suing a doctor or hospital (and subsequently their insurance company) is easier said than done. Birth injury lawsuits are some of the most complex cases that exist. That’s why you need to seek legal help from a birth injury law firm. (Not a law firm that sometimes takes on birth injury cases.) To discuss a potential case with our knowledgeable, compassionate lawyers, schedule a free consultation here .

POST CATEGORIES:

Brain Injuries
Nursing Negligence
Pregancy-Related Injuries
Uncategorized
Wrongful Death

Obstetric Outcomes in Military Servicewomen: Emerging Knowledge, Considerations, and Gaps

Affiliations.

1 Boston University School of Public Health, Boston, Massachusetts.
2 Boston University School of Medicine, Boston, Massachusetts.
PMID: 32588420
DOI: 10.1055/s-0040-1712929

The number of women in the U.S. military is dramatically increasing. Similarly, the roles of active-duty women are greatly expanding, thus exposing them to new occupational risks. Determining the impact of pregnancy outcomes for women while in the military is difficult due to changing exposures over time, difficulty in utilizing appropriate comparison groups, and the lack of prospective investigations. Despite these limitations, it was concerning that the available data suggest that servicewomen delivering within 6 months of their first deployment have an increased preterm birth risk (adjusted odds ratio [aOR]: 2.1), and those with three prior deployments have an even greater risk (aOR: 3.8). Servicewomen also have an increased risk of hypertensive disorders with a rate of 13% compared with 5% in the general obstetric population. Furthermore, depression is higher for women who deploy after childbirth and are exposed to combat when compared with those who have not deployed since the birth of their child (aOR: 2.01). Due to the importance of this issue, prospective research designs are necessary to better understand and address the unique health care needs of this population.

Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

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Military Women at Greater Risk of Having Babies with Low Birth Weight, Scientific Review Finds

A U.S. Army Certified Nurse Midwife measures baby's heart rate

Women in the military could have a higher risk of giving birth to low-weight babies than their civilian counterparts, according to a scientific review published this week.

The review, which analyzed 21 separate studies of pregnancies in the U.S. military from 1979 to 2023, found that about two-thirds of the studies concluded that active-duty servicewomen may be at heightened risk of having babies with a low birth weight.

Still, the review did not find clear evidence that servicewomen have an increased risk of stillbirth or premature births.

Read Next: Navy Chief Petty Officer Convicted of Attempted Espionage at San Diego Court-Martial

The review, which was written by U.K. researchers and published in the journal BMJ Military Health , "highlights a need for female-specific research in other armed forces " beyond the U.S. military, the authors concluded.

"From the service perspective, promoting the health of mother and baby can contribute to operational effectiveness through faster return to duty, retention in the service and increased deployability," the researchers, led by Kirsten Morris of the London School of Hygiene and Tropical Medicine, wrote in the review published Monday. "Hence, improved pregnancy outcomes are important both for the families concerned and for the service as a whole."

While the researchers were focused on the implications of the review on militaries outside the United States, U.S. policymakers have also been concerned about maternal health in the military in recent years.

Concern in the U.S. has focused both on how the unique stressors of military life could affect pregnancy as well as on a lack of access to maternity care within the military health system.

Staffing shortages in general at military treatment facilities have left expectant mothers struggling to find a doctor. The issue has been a particular worry in areas where local doctors don't have the capacity to handle an influx of military patients, as well as for those stationed overseas where treatment may differ from what U.S. patients expect.

A 2023 study also found that patient satisfaction ratings for obstetric care in military health facilities are low compared to medical and surgical care.

Meanwhile, evidence has accumulated showing the stress of military life hits pregnant service members particularly hard. For example, a 2022 Government Accountability Office report found service members face mental health conditions during the perinatal period at a higher rate than civilians.

U.S. lawmakers have proposed fixes, including mandating a comprehensive study of access to maternity care and creating a perinatal mental health program . Women's health was also one of the specialty areas of health care that a bipartisan House panel on military quality-of-life recently recommended taking steps to increase access to.

The scientific review released Monday also noted that a growing body of research shows that stress both before conception and during pregnancy is associated with birth complications, including low birth weight and premature birth.

Low birth weight is considered anything less than 5 pounds, 8 ounces, and is associated with health concerns, including breathing issues, developmental disabilities and chronic diseases later in life, according to nonprofit maternal health organization March of Dimes.

The 21 studies that the researchers analyzed covered the experiences of more than 650,000 U.S. servicewomen, according to the review.

In addition to finding that U.S. service members in general appeared at greater risk of having babies with low birth weight than civilians, the researchers noted both studies they examined from the Air Force indicated a higher prevalence of low birth weight specifically in that service.

The researchers also stressed several limitations with their review, including that many of the studies didn't have a control group and relied on national statistics for comparison, and that few of the studies looked at other risk factors such as smoking habits.

Still, the researchers concluded that their findings could be used to "inform military maternity pathways and policies in ways that safeguard mothers and their babies while enhancing military readiness."

Related: With Hourlong Drives and Weeks Until Appointments, Pregnant Military Women Feel Pain of Medical Reforms

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‘It bucked our lads up wonderfully’: the lightning-quick battle that marked the birth of the US-Australia military alliance

Associate Professor of Strategic & Defence Studies, Australian National University

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Meighen McCrae does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.

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While the AUKUS alliance is new, the Australian-American partnership is not. As Australians reflect on the sacrifices of their soldiers on ANZAC Day, it’s worth remembering the first time Australian and American troops joined forces in battle – in northern France, in the final year of the first world war.

Australia fought as part of the British Empire in the early 20th century. This meant that when Britain declared war in 1914 against the Central Powers (Germany, Austria-Hungary and the Ottoman empire), Australia immediately went to war on the side of the Allies (the British, French, Russian and Japanese empires, with Italy and the United States joining later).

The US didn’t fully commit to the Allied cause until April 1917. Once it did, it focused on building up its industrial war machine and recruiting troops to be sent to Europe. By July 1918, there were around a million American soldiers in France, with more arriving every day.

As I describe in my book, Coalition Strategy and the End of the First World War , from the Allied perspective, the war still very much hung in the balance. They knew the Germans were a formidable enemy, as the launch of the German Spring Offensives in March 1918 had shown.

The Allies had some battle successes beginning in June 1918 that slowly built their confidence. One of the important engagements would become known as the Battle of Hamel in northern France. This was when the Australian overall commander, Lieutenant General John Monash , spearheaded the first Australian-American attack in history. Monash organised the offensive for July 4, American Independence Day.

American and Australian troops during the battle.

A quick victory, with limited casualties

Ahead of the battle, American forces moved into Australian lines. As Australian Lieutenant Edgar Rule described :

Twelve were put in each platoon, and believe me they were some men. This was the first time that they had been in the line, and they were dead keen; and apart from that it bucked our lads up wonderfully. All the novelty of the war had long since vanished for our boys … everyone was smiling or laughing. The Yanks were out for information and our boys were very willing teachers, and it speaks well for the future to see one set so eager to learn and the other so willing to teach.

Despite Monash’s best intentions, however, the American supreme commander, General John “Black Jack” Pershing , was not pleased. Americans supporting Australia in a defensive role was one thing. Attacking, however, would involve higher casualty rates and reduce the strength of the US forces at a time when Pershing wanted to have his own sector of the battlefield, rather than have his troops fed into other armies.

As a result, Pershing went so far as to withdraw six of his companies from the attack and then threatened to withdraw the remaining four. This treatment was not reserved for Monash. Many of the Allied commanders found Pershing difficult to work with – and Monash was no exception.

At 3:10am on July 4, 1918, Australian infantry, including four companies of the American 33rd Division, attacked the Germans in the town of Hamel. They moved forward under the protection of a “creeping barrage” (a slow-moving curtain of artillery fire that protects advancing troops and pins down enemy forces) and with the support of both aircraft and tanks.

Both the Australian Flying Corps and British Royal Air Force were used to prepare for and conduct the attack. This was the first major war in which armies used aircraft in large numbers. And the Battle of Hamel was the first time aircraft were used to parachute supplies to troops on the ground.

Within 93 minutes, the battle was over – and it was a success. The Australian-American forces had achieved their objective of gaining important ground – in this case, guarding the vital rail centre of Amiens – while limiting the loss of life. Casualties were comparatively low for the war, with around 800 killed.

An excerpt from the citation of an Australian Victoria Cross recipient, Private Henry Dalziel , illustrates how tough the battle was:

He twice went over open ground under heavy enemy artillery and machine-gun fire to secure ammunition, and though suffering from considerable loss of blood, he filled magazines and served his gun until severely wounded through the head. His magnificent bravery and devotion to duty was an inspiring example to all his comrades, and his dash and unselfish courage at a most critical time undoubtedly saved many lives.

Dalziel survived the war and went on to be a songwriter.

Read more: Poetry, parties and 'strong Australian tea'. The surprising story of how Anzac Day has been marked in the US for over 100 years

A rapid end of the war

Apart from demonstrating extraordinary courage, the Battle of Hamel is a case study of meticulous planning, excellent staff work and coordination of infantry, artillery, tanks and aircraft.

An Australian soldier asleep after the Battle of Hamel.

Indeed, the battle helped vindicate ideas about short, sharp attacks from mutually supporting Allied armies (which the Allied generalissimo, Ferdinand Foch referred to as “punching and kicking” the German lines), as well as the combined use of infantry, creeping barrage, tanks and aircraft. It had taken several years of battle experience to reach this point.

These ideas culminated five weeks later with the unprecedented Allied success of the nearby Battle of Amiens , which saw all available Australian spearhead the attack. It was Australia’s biggest victory of the war to that point.

The Australians also fought in the Battle of Mont Saint-Quentin in late August before again joining forces with the Americans and other Allied forces to smash through the Hindenburg Line in September.

By this point, it finally looked as though the tide had turned. The Allies began to envision an end to the conflict in late 1918 rather than in 1919, as they were planning for , Indeed, in less than two months, the fighting was over and the Allies were victorious.

Australian soldiers search their German prisoners.

For Australia, the end of the war could not come soon enough. The Hindenburg Line was the last offensive for them, as hard fighting over the previous two years had savagely reduced their troop numbers.

However, this was just the beginning of a long military partnership between the US and Australia, forged in shared battle experience and a growing trust, which has now lasted for more than a hundred years.

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Fetal Positions For Birth: Presentation, Types & Function
Occiput or cephalic anterior: This is the best fetal position for childbirth. It means the fetus is head down, facing the birth parent's spine (facing backward). Its chin is tucked towards its chest. The fetus will also be slightly off-center, with the back of its head facing the right or left. This is called left occiput anterior or right ...
Fetal Presentation, Position, and Lie (Including Breech Presentation
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 ...
Fetal Presentation, Position, and Lie (Including Breech Presentation
In face presentation, the head is hyperextended, and position is designated by the position of the chin (mentum). When the chin is posterior, the head is less likely to rotate and less likely to deliver vaginally, necessitating cesarean delivery. Brow presentation usually converts spontaneously to vertex or face presentation.
Fetal Presentation
Fetal presentation means the part of the fetus that is "presenting" at the cervix: Cephalic presentation means head first. This is the normal presentation. Breech presentation means the fetal butt is coming out first. Transverse lie means the fetus is oriented from one side of the mother to the other and neither the head nor the butt is ...
PDF 1. When discussing fetal location, what does the term ...
Denominator is the location of the fetus that gives the most information about the presentation. If the baby is cephalic and vertex ten the occiput bone will be the first visible part of the baby. If it is a brow presentation then the forehead is seen first, if it is a face presentation then the chin is the presenting part.
Delivery, Face and Brow Presentation
The term presentation describes the leading part of the fetus or the anatomical structure closest to the maternal pelvic inlet during labor. The presentation can roughly be divided into the following classifications: cephalic, breech, shoulder, and compound. Cephalic presentation is the most common and can be further subclassified as vertex, sinciput, brow, face, and chin. The most common ...
Presentation (obstetrics)
Presentation of twins in Der Rosengarten ("The Rose Garden"), a standard medical text for midwives published in 1513. In obstetrics, the presentation of a fetus about to be born specifies which anatomical part of the fetus is leading, that is, is closest to the pelvic inlet of the birth canal. According to the leading part, this is identified as a cephalic, breech, or shoulder presentation.
Fetal presentation before birth
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.
Fetal Position
Fetal position reflects the orientation of the fetal head or butt within the birth canal. Anterior Fontanel The bones of the fetal scalp are soft and meet at "suture lines." Over the forehead, where the bones meet, is a gap, called the "anterior fontanel," or "soft spot." This will close as the baby grows during.
Vertex Presentation: Position, Birth & What It Means
The vertex presentation describes the orientation a fetus should be in for a safe vaginal delivery. It becomes important as you near your due date because it tells your pregnancy care provider how they may need to deliver your baby. Vertex means "crown of the head.". This means that the crown of the fetus's head is presenting towards the ...
Abnormal Fetal Lie and Presentation
Birth trauma, particularly to the head and cervical spine, is a significant risk to both term and preterm infants who present as breech presentation or in a nonaxial lie. 7, 8, 9 Unlike the cephalic fetus in whom hours of adaptation to the maternal bony pelvis (molding) may occur, the after-coming head of the breech fetus must descend and ...
Delivery, Face Presentation, and Brow Presentation ...
Brow Presentation: Definition: Brow presentation occurs when the baby's head is partially extended, causing the brow (forehead) to lead the way through the birth canal. Causes: Brow presentation may result from abnormal fetal positioning, poor engagement of the fetal head, or other factors that prevent full flexion or extension.
Face and Brow Presentation: Overview, Background, Mechanism ...
In a face presentation, the fetal head and neck are hyperextended, causing the occiput to come in contact with the upper back of the fetus while lying in a longitudinal axis. The presenting portion of the fetus is the fetal face between the orbital ridges and the chin. The fetal chin (mentum) is the point designated for reference during an ...
The Trusted Provider of Medical Information since 1899
The Trusted Provider of Medical Information since 1899
My Sinciput (or Military) Position Birth Story, and How a Dream Helped
Pushing Part 1. My body began getting that pushy feeling around 8:30pm. In unmedicated, undirected labors, it is more noticeable that the mothers/birthers body begins pushing when it's ready. The mom/birther sounds and looks "pushy". After 2 -3 hours of pushing, the midwives decided to "check", or examine the cervix.
Breech Delivery
Breech delivery is the single most common abnormal presentation. The incidence is highly dependent on the gestational age. At 20 weeks, about one in four pregnancies are breech presentation. By full term, the incidence is about 4%. Other contributing factors include: Abnormal shape of the pelvis, uterus, or abdominal wall, Anatomical malformation of the fetus,
Abnormal Fetal Position/Presentation and Birth Injury
Vertex presentation is the 'normal' way that a baby is positioned for birth and the lowest-risk presentation for vaginal birth (1). 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 ...
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Face Presentation Causes & Risk Factors. These conditions may increase the likelihood of a face presentation birth: A Very Big Baby (Fetal Macrosomia): Larger babies may have trouble fitting into the birth canal in the standard position, leading to alternative presentations. Prematurity: Premature infants are more likely to have non-standard presentations, including face presentation, because ...
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Servicewomen also have an increased risk of hypertensive disorders with a rate of 13% compared with 5% in the general obstetric population. Furthermore, depression is higher for women who deploy after childbirth and are exposed to combat when compared with those who have not deployed since the birth of their child (aOR: 2.01).
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Presentation of 2023 Regional Military Conservation Partner Award to Fort Drum. Photo By/Credit. Mike Strasser /Fort Drum Garrison Public Affairs. Copy Credit . Date Shot/Created. 12/04/2023. ... Military. Partnerships. Working with others to conserve, protect and enhance fish, wildlife, plants and their habitats for the continuing benefit of ...

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

Transverse lie

Breech presentation

Types of breech presentations

Face or brow presentation

Occiput posterior position

Position and Presentation of the Fetus

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Delivery, Face Presentation, and Brow Presentation: Understanding Fetal Positions and Birth Scenarios

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

Position and Presentation of the Fetus

Occiput posterior position

Breech presentation

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My Sinciput (or Military) Position Birth Story, and How a Dream Helped me Through it

Water Breaking

Early Labor

Pushing Part 1

Pushing Part 2

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Military Obstetrics & Gynecology – 3rd Edition

Types of Breech Presentation

Risks of Vaginal Breech Delivery

Risk Factors

Spontaneous Breech Delivery

Assisted Breech Delivery

Entrapped Head

Nuchal Arms

Military Settings

Women's Healthcare in Operational Settings

Abnormal Fetal Position and Presentation

What is the difference between fetal presentation and position?

What way should a baby come out during birth?

What happens if a baby isn’t in the standard vertex position during birth?

Compound presentation

Limb presentation

Occipitoposterior (OP) position

Breech presentation

There are 4 types of breech positions:

Face presentation

There are three types of face presentation:

Listed below are complications that can occur if face presentation is mismanaged by the medical team:

Brow presentation

Risk factors and conditions associated with brow presentation

Diagnosis of brow presentation

Management of brow presentation

Complications of brow presentation

Shoulder presentation (transverse lie)