types of birth presentations

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• Fetal presentation before birth

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

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

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

Head down, face down

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

Head down, face up

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

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

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

Frank breech

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

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

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

Complete and incomplete breech

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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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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• Sonographic diagnosis of fetal head deflexion and the risk of cesarean delivery. [Am J Obstet Gynecol MFM. 2020] Sonographic diagnosis of fetal head deflexion and the risk of cesarean delivery. Bellussi F, Livi A, Cataneo I, Salsi G, Lenzi J, Pilu G. Am J Obstet Gynecol MFM. 2020 Nov; 2(4):100217. Epub 2020 Aug 18.
• Review Sonographic evaluation of the fetal head position and attitude during labor. [Am J Obstet Gynecol. 2024] Review Sonographic evaluation of the fetal head position and attitude during labor. Ghi T, Dall'Asta A. Am J Obstet Gynecol. 2024 Mar; 230(3S):S890-S900. Epub 2023 May 19.
• Leopold Maneuvers. [StatPearls. 2024] Leopold Maneuvers. Superville SS, Siccardi MA. StatPearls. 2024 Jan
• Intrapartum sonographic assessment of the fetal head flexion in protracted active phase of labor and association with labor outcome: a multicenter, prospective study. [Am J Obstet Gynecol. 2021] Intrapartum sonographic assessment of the fetal head flexion in protracted active phase of labor and association with labor outcome: a multicenter, prospective study. Dall'Asta A, Rizzo G, Masturzo B, Di Pasquo E, Schera GBL, Morganelli G, Ramirez Zegarra R, Maqina P, Mappa I, Parpinel G, et al. Am J Obstet Gynecol. 2021 Aug; 225(2):171.e1-171.e12. Epub 2021 Mar 4.
• Review Labor with abnormal presentation and position. [Obstet Gynecol Clin North Am. ...] Review Labor with abnormal presentation and position. Stitely ML, Gherman RB. Obstet Gynecol Clin North Am. 2005 Jun; 32(2):165-79.

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

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

Fetal presentation and position

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

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

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

Medical illustrations by Jonathan Dimes

Head down, facing down (anterior position)

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

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

Head down, facing up (posterior position)

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

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

Frank breech

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

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

Complete breech

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

Incomplete breech

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

Single footling breech

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

Double footling breech

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

Transverse lie

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

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

Oblique lie

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

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

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

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

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

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

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

Where to go next

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 .

Other presentations

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

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

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

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

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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 vertex 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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Malpresentations and malpositions

Peer reviewed by Dr Laurence Knott Last updated by Dr Colin Tidy, MRCGP Last updated 22 Jun 2021

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Professional Reference articles are designed for health professionals to use. They are written by UK doctors and based on research evidence, UK and European Guidelines. You may find one of our  health articles  more useful.

In this article :

Malpresentation, malposition.

Usually the fetal head engages in the occipito-anterior position (more often left occipito-anterior (LOA) rather than right) and then undergoes a short rotation to be directly occipito-anterior in the mid-cavity. Malpositions are abnormal positions of the vertex of the fetal head relative to the maternal pelvis. Malpresentations are all presentations of the fetus other than vertex.

Obstetrics - the pelvis and head

Continue reading below

Predisposing factors to malpresentation include:

Prematurity.

Multiple pregnancy.

Abnormalities of the uterus - eg, fibroids.

Partial septate uterus.

Abnormal fetus.

Placenta praevia.

Primiparity.

Breech presentation

See the separate Breech Presentations article for more detailed discussion.

Breech presentation is the most common malpresentation, with the majority discovered before labour. Breech presentation is much more common in premature labour.

Approximately one third are diagnosed during labour when the fetus can be directly palpated through the cervix.

After 37 weeks, external cephalic version can be attempted whereby an attempt is made to turn the baby manually by manipulating the pregnant mother's abdomen. This reduces the risk of non-cephalic delivery 1 .

Maternal postural techniques have also been tried but there is insufficient evidence to support these 2 .

Many women who have a breech presentation can deliver vaginally. Factors which make this less likely to be successful include 3 :

Hyperextended neck on ultrasound.

High estimated fetal weight (more than 3.8 kg).

Low estimated weight (less than tenth centile).

Footling presentation.

Evidence of antenatal fetal compromise.

Transverse lie 4

When the fetus is positioned with the head on one side of the pelvis and the buttocks in the other (transverse lie), vaginal delivery is impossible.

This requires caesarean section unless it converts or is converted late in pregnancy. The surgeon may be able to rotate the fetus through the wall of the uterus once the abdominal wall has been opened. Otherwise, a transverse uterine incision is needed to gain access to a fetal pole.

Internal podalic version is no longer attempted.

Transverse lie is associated with a risk of cord prolapse of up to 20%.

Occipito-posterior position

This is the most common malposition where the head initially engages normally but then the occiput rotates posteriorly rather than anteriorly. 5.2% of deliveries are persistent occipito-posterior 5 .

The occipito-posterior position results from a poorly flexed vertex. The anterior fontanelle (four radiating sutures) is felt anteriorly. The posterior fontanelle (three radiating sutures) may also be palpable posteriorly.

It may occur because of a flat sacrum, poorly flexed head or weak uterine contractions which may not push the head down into the pelvis with sufficient strength to produce correct rotation.

As occipito-posterior-position pregnancies often result in a long labour, close maternal and fetal monitoring are required. An epidural is often recommended and it is essential that adequate fluids be given to the mother.

The mother may get the urge to push before full dilatation but this must be discouraged. If the head comes into a face-to-pubis position then vaginal delivery is possible as long as there is a reasonable pelvic size. Otherwise, forceps or caesarean section may be required.

Occipito-transverse position

The head initially engages correctly but fails to rotate and remains in a transverse position.

Alternatives for delivery include manual rotation of fetal head using Kielland's forceps, or delivery using vacuum extraction. This is inappropriate if there is any fetal acidosis because of the risk of cerebral haemorrhage.

Therefore, there must be provision for a failure of forceps delivery to be changed immediately to a caesarean. The trial of forceps is therefore often performed in theatre. Some centres prefer to manage by caesarean section without trial of forceps.

Face presentations

Face presents for delivery if there is complete extension of the fetal head.

Face presentation occurs in 1 in 1,000 deliveries 5 .

With adequate pelvic size, and rotation of the head to the mento-anterior position, vaginal delivery should be achieved after a long labour.

Backwards rotation of the head to a mento-posterior position requires a caesarean section.

Brow positions

The fetal head stays between full extension and full flexion so that the biggest diameter (the mento-vertex) presents.

Brow presentation occurs in 0.14% of deliveries 5 .

Brow presentation is usually only diagnosed once labour is well established.

The anterior fontanelle and super orbital ridges are palpable on vaginal examination.

Unless the head flexes, a vaginal delivery is not possible, and a caesarean section is required.

Further reading and references

• Hofmeyr GJ, Kulier R, West HM ; External cephalic version for breech presentation at term. Cochrane Database Syst Rev. 2015 Apr 1;(4):CD000083. doi: 10.1002/14651858.CD000083.pub3.
• Hofmeyr GJ, Kulier R ; Cephalic version by postural management for breech presentation. Cochrane Database Syst Rev. 2012 Oct 17;10:CD000051. doi: 10.1002/14651858.CD000051.pub2.
• Management of Breech Presentation ; Royal College of Obstetricians and Gynaecologists (Mar 2017)
• Szaboova R, Sankaran S, Harding K, et al ; PLD.23 Management of transverse and unstable lie at term. Arch Dis Child Fetal Neonatal Ed. 2014 Jun;99 Suppl 1:A112-3. doi: 10.1136/archdischild-2014-306576.324.
• Gardberg M, Leonova Y, Laakkonen E ; Malpresentations - impact on mode of delivery. Acta Obstet Gynecol Scand. 2011 May;90(5):540-2. doi: 10.1111/j.1600-0412.2011.01105.x.

Article history

The information on this page is written and peer reviewed by qualified clinicians.

Next review due: 21 Jun 2026

22 jun 2021 | latest version.

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Fetal Presentation: Baby’s First Pose

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Occiput Anterior

Occiput posterior, transverse position, complete breech, frank breech, changing fetal presentation, baby positions.

The position in which your baby develops is called the “fetal presentation.” During most of your pregnancy, the baby will be curled up in a ball – that’s why we call it the “fetal position.” The baby might flip around over the course of development, which is why you can sometimes feel a foot poking into your side or an elbow prodding your bellybutton. As you get closer to delivery, the baby will change positions and move lower in your uterus in preparation. Over the last part of your pregnancy, your doctor or medical care provider will monitor the baby’s position to keep an eye out for any potential problems.

In the occiput anterior position, the baby is pointed headfirst toward the birth canal and is facing down – toward your back. This is the easiest possible position for delivery because it allows the crown of the baby’s head to pass through first, followed by the shoulders and the rest of the body. The crown of the head is the narrowest part, so it can lead the way for the rest of the head.

The baby’s head will move slowly downward as you get closer to delivery until it “engages” with your pelvis. At that point, the baby’s head will fit snugly and won’t be able to wobble around. That’s exactly where you want to be just before labor. The occiput anterior position causes the least stress on your little one and the easiest labor for you.

In the occiput posterior position, the baby is pointed headfirst toward the birth canal but is facing upward, toward your stomach. This can trap the baby’s head under your pubic bone, making it harder to get out through the birth canal. In most cases, a baby in the occiput posterior position will either turn around naturally during the course of labor or your doctor or midwife may help it along manually or with forceps.

In a transverse position, the baby is sideways across the birth canal rather than head- or feet-first. It’s rare for a baby to stay in this position all the way up to delivery, but your doctor may attempt to gently push on your abdomen until the baby is in a more favorable fetal presentation. If you go into labor while the baby is in a transverse position, your medical care provider will likely recommend a c-section to avoid stressing or injuring the baby.

Breech Presentation

If the baby’s legs or buttocks are leading the way instead of the head, it’s called a breech presentation. It’s much harder to deliver in this position – the baby’s limbs are unlikely to line up all in the right direction and the birth canal likely won’t be stretched enough to allow the head to pass. Breech presentation used to be extremely dangerous for mothers and children both, and it’s still not easy, but medical intervention can help.

Sometimes, the baby will turn around and you’ll be able to deliver vaginally. Most healthcare providers, however, recommend a cesarean section for all breech babies because of the risks of serious injury to both mother and child in a breech vaginal delivery.

A complete breech position refers to the baby being upside down for delivery – feet first and head up. The baby’s legs are folded up and the feet are near the buttocks.

In a frank breech position, the baby’s legs are extended and the baby’s buttocks are closest to the birth canal. This is the most common breech presentation .

By late in your pregnancy, your baby can already move around – you’re probably feeling those kicks! Unfortunately, your little one doesn’t necessarily know how to aim for the birth canal. If the baby isn’t in the occiput anterior position by about 32 weeks, your doctor or midwife will typically recommend trying adjust the fetal presentation. They’ll use monitors to keep an eye on the baby and watch for signs of stress as they push and lift on your belly to coax your little one into the right spot. Your doctor may also advise you to try certain exercises at home to encourage the baby to move into the proper position. For example, getting on your hands and knees for a few minutes every day can help bring the baby around. You can also put cushions on your chairs to make sure your hips are always elevated, which can help move things into the right place. It’s important to start working on the proper fetal position early, as it becomes much harder to adjust after about 37 weeks when there’s less room to move around.

In many cases, the baby will eventually line up properly before delivery. Sometimes, however, the baby is still in the wrong spot by the time you go into labor. Your doctor or midwife may be able to move the baby during labor using forceps or ventouse . If that’s not possible, it’s generally safer for you and the baby if you deliver by c-section.

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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

On the Article

Krish Tangella MD, MBA

Alexander Enabnit

Alexandra Warren

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Abnormal Fetal lie, Malpresentation and Malposition

Original Author(s): Anna Mcclune Last updated: 1st December 2018 Revisions: 12

• 1 Definitions
• 2 Risk Factors
• 3.2 Presentation
• 3.3 Position
• 4 Investigations
• 5.1 Abnormal Fetal Lie
• 5.2 Malpresentation
• 5.3 Malposition

The lie, presentation and position of a fetus are important during labour and delivery.

In this article, we will look at the risk factors, examination and management of abnormal fetal lie, malpresentation and malposition.

Definitions

• Longitudinal, transverse or oblique
• Cephalic vertex presentation is the most common and is considered the safest
• Other presentations include breech, shoulder, face and brow
• Usually the fetal head engages in the occipito-anterior position (the fetal occiput facing anteriorly) – this is ideal for birth
• Other positions include occipito-posterior and occipito-transverse.

Note: Breech presentation is the most common malpresentation, and is covered in detail here .

Fig 1 – The two most common fetal presentations: cephalic and breech.

Risk Factors

The risk factors for abnormal fetal lie, malpresentation and malposition include:

• Multiple pregnancy
• Uterine abnormalities (e.g fibroids, partial septate uterus)
• Fetal abnormalities
• Placenta praevia
• Primiparity

Identifying Fetal Lie, Presentation and Position

The fetal lie and presentation can usually be identified via abdominal examination. The fetal position is ascertained by vaginal examination.

For more information on the obstetric examination, see here .

• Face the patient’s head
• Place your hands on either side of the uterus and gently apply pressure; one side will feel fuller and firmer – this is the back, and fetal limbs may feel ‘knobbly’ on the opposite side

Presentation

• Palpate the lower uterus (above the symphysis pubis) with the fingers of both hands; the head feels hard and round (cephalic) and the bottom feels soft and triangular (breech)
• You may be able to gently push the fetal head from side to side

The fetal lie and presentation may not be possible to identify if the mother has a high BMI, if she has not emptied her bladder, if the fetus is small or if there is polyhydramnios .

During labour, vaginal examination is used to assess the position of the fetal head (in a cephalic vertex presentation). The landmarks of the fetal head, including the anterior and posterior fontanelles, indicate the position.

Fig 2 – Assessing fetal lie and presentation.

Investigations

Any suspected abnormal fetal lie or malpresentation should be confirmed by an ultrasound scan . This could also demonstrate predisposing uterine or fetal abnormalities.

Abnormal Fetal Lie

If the fetal lie is abnormal, an external cephalic version (ECV) can be attempted – ideally between 36 and 38 weeks gestation.

ECV is the manipulation of the fetus to a cephalic presentation through the maternal abdomen.

It has an approximate success rate of 50% in primiparous women and 60% in multiparous women. Only 8% of breech presentations will spontaneously revert to cephalic in primiparous women over 36 weeks gestation.

Complications of ECV are rare but include fetal distress , premature rupture of membranes, antepartum haemorrhage (APH) and placental abruption. The risk of an emergency caesarean section (C-section) within 24 hours is around 1 in 200.

ECV is contraindicated in women with a recent APH, ruptured membranes, uterine abnormalities or a previous C-section .

Fig 3 – External cephalic version.

Malpresentation

The management of malpresentation is dependent on the presentation.

• Breech – attempt ECV before labour, vaginal breech delivery or C-section
• Brow – a C-section is necessary
• If the chin is anterior (mento-anterior) a normal labour is possible; however, it is likely to be prolonged and there is an increased risk of a C-section being required
• If the chin is posterior (mento-posterior) then a C-section is necessary
• Shoulder – a C-section is necessary

Malposition

90% of malpositions spontaneously rotate to occipito-anterior as labour progresses. If the fetal head does not rotate, rotation and operative vaginal delivery can be attempted. Alternatively a C-section can be performed.

• Usually the fetal head engages in the occipito-anterior position (the fetal occiput facing anteriorly) - this is ideal for birth

If the fetal lie is abnormal, an external cephalic version (ECV) can be attempted - ideally between 36 and 38 weeks gestation.

• Breech - attempt ECV before labour, vaginal breech delivery or C-section

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Face and Brow Presentation

• Author: Teresa Marino, MD; Chief Editor: Carl V Smith, MD  more...
• Sections Face and Brow Presentation
• Mechanism of Labor
• Labor Management

At the onset of labor, assessment of the fetal presentation with respect to the maternal birth canal is critical to the route of delivery. At term, the vast majority of fetuses present in the vertex presentation, where the fetal head is flexed so that the chin is in contact with the fetal thorax. The fetal spine typically lies along the longitudinal axis of the uterus. Nonvertex presentations (including breech, transverse lie, face, brow, and compound presentations) occur in less than 4% of fetuses at term. Malpresentation of the vertex presentation occurs if there is deflexion or extension of the fetal head leading to brow or face presentation, respectively.

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 internal examination through the cervix. The occiput of a vertex is usually hard and has a smooth contour, while the face and brow tend to be more irregular and soft. Like the occiput, the mentum can present in any position relative to the maternal pelvis. For example, if the mentum presents in the left anterior quadrant of the maternal pelvis, it is designated as left mentum anterior (LMA).

In a brow presentation, the fetal head is midway between full flexion (vertex) and hyperextension (face) along a longitudinal axis. The presenting portion of the fetal head is between the orbital ridge and the anterior fontanel. The face and chin are not included. The frontal bones are the point of designation and can present (as with the occiput during a vertex delivery) in any position relative to the maternal pelvis. When the sagittal suture is transverse to the pelvic axis and the anterior fontanel is on the right maternal side, the fetus would be in the right frontotransverse position (RFT).

Face presentation occurs in 1 of every 600-800 live births, averaging about 0.2% of live births. Causative factors associated with a face presentation are similar to those leading to general malpresentation and those that prevent head flexion or favor extension. Possible etiology includes multiple gestations, grand multiparity, fetal malformations, prematurity, and cephalopelvic disproportion. At least one etiological factor may be identified in up to 90% of cases with face presentation.

Fetal anomalies such as hydrocephalus, anencephaly, and neck masses are common risk factors and may account for as many as 60% of cases of face presentation. For example, anencephaly is found in more than 30% of cases of face presentation. Fetal thyromegaly and neck masses also lead to extension of the fetal head.

A contracted pelvis or cephalopelvic disproportion, from either a small pelvis or a large fetus, occurs in 10-40% of cases. Multiparity or a large abdomen can cause decreased uterine tone, leading to natural extension of the fetal head.

Face presentation is diagnosed late in the first or second stage of labor by examination of a dilated cervix. On digital examination, the distinctive facial features of the nose, mouth, and chin, the malar bones, and particularly the orbital ridges can be palpated. This presentation can be confused with a breech presentation because the mouth may be confused with the anus and the malar bones or orbital ridges may be confused with the ischial tuberosities. The facial presentation has a triangular configuration of the mouth to the orbital ridges compared to the breech presentation of the anus and fetal genitalia. During Leopold maneuvers, diagnosis is very unlikely. Diagnosis can be confirmed by ultrasound evaluation, which reveals a hyperextended fetal neck. [ 1 , 2 ]

Brow presentation is the least common of all fetal presentations and the incidence varies from 1 in 500 deliveries to 1 in 1400 deliveries. Brow presentation may be encountered early in labor but is usually a transitional state and converts to a vertex presentation after the fetal neck flexes. Occasionally, further extension may occur resulting in a face presentation.

The causes of a persistent brow presentation are generally similar to those causing a face presentation and include cephalopelvic disproportion or pelvic contracture, increasing parity and prematurity. These are implicated in more than 60% of cases of persistent brow presentation. Premature rupture of membranes may precede brow presentation in as many as 27% of cases.

Diagnosis of a brow presentation can occasionally be made with abdominal palpation by Leopold maneuvers. A prominent occipital prominence is encountered along the fetal back, and the fetal chin is also palpable; however, the diagnosis of a brow presentation is usually confirmed by examination of a dilated cervix. The orbital ridge, eyes, nose, forehead, and anterior fontanelle are palpated. The mouth and chin are not palpable, thus excluding face presentation. Fetal ultrasound evaluation again notes a hyperextended neck.

As with face presentation, diagnosis is often made late in labor with half of cases occurring in the second stage of labor. The most common position is the mentum anterior, which occurs about twice as often as either transverse or posterior positions. A higher cesarean delivery rate occurs with a mentum transverse or posterior [ 3 ] position than with a mentum anterior position.

The mechanism of labor consists of the cardinal movements of engagement, descent, flexion, internal rotation, and the accessory movements of extension and external rotation. Intuitively, the cardinal movements of labor for a face presentation are not completely identical to those of a vertex presentation.

While descending into the pelvis, the natural contractile forces combined with the maternal pelvic architecture allow the fetal head to either flex or extend. In the vertex presentation, the vertex is flexed such that the chin rests on the fetal chest, allowing the suboccipitobregmatic diameter of approximately 9.5 cm to be the widest diameter through the maternal pelvis. This is the smallest of the diameters to negotiate the maternal pelvis. Following engagement in the face presentation, descent is made. The widest diameter of the fetal head negotiating the pelvis is the trachelobregmatic or submentobregmatic diameter, which is 10.2 cm (0.7 cm larger than the suboccipitobregmatic diameter). Because of this increased diameter, engagement does not occur until the face is at +2 station.

Fetuses with face presentation may initially begin labor in the brow position. Using x-ray pelvimetry in a series of 7 patients, Borrell and Ferstrom demonstrated that internal rotation occurs between the ischial spines and the ischial tuberosities, making the chin the presenting part, lower than in the vertex presentation. [ 4 , 5 ] Following internal rotation, the mentum is below the maternal symphysis, and delivery occurs by flexion of the fetal neck. As the face descends onto the perineum, the anterior fetal chin passes under the symphysis and flexion of the head occurs, making delivery possible with maternal expulsive forces.

The above mechanisms of labor in the term infant can occur only if the mentum is anterior and at term, only the mentum anterior face presentation is likely to deliver vaginally. If the mentum is posterior or transverse, the fetal neck is too short to span the length of the maternal sacrum and is already at the point of maximal extension. The head cannot deliver as it cannot extend any further through the symphysis and cesarean delivery is the safest route of delivery.

Fortunately, the mentum is anterior in over 60% of cases of face presentation, transverse in 10-12% of cases, and posterior only 20-25% of the time. Fetuses with the mentum transverse position usually rotate to the mentum anterior position, and 25-33% of fetuses with mentum posterior position rotate to a mentum anterior position. When the mentum is posterior, the neck, head and shoulders must enter the pelvis simultaneously, resulting in a diameter too large for the maternal pelvis to accommodate unless in the very preterm or small infant.

Three labor courses are possible when the fetal head engages in a brow presentation. The brow may convert to a vertex presentation, to a face presentation, or remain as a persistent brow presentation. More than 50% of brow presentations will convert to vertex or face presentation and labor courses are managed accordingly when spontaneous conversion occurs.

In the brow presentation, the occipitomental diameter, which is the largest diameter of the fetal head, is the presenting portion. Descent and internal rotation occur only with an adequate pelvis and if the face can fit under the pubic arch. While the head descends, it becomes wedged into the hollow of the sacrum. Downward pressure from uterine contractions and maternal expulsive forces may cause the mentum to extend anteriorly and low to present at the perineum as a mentum anterior face presentation.

If internal rotation does not occur, the occipitomental diameter, which measures 1.5 cm wider than the suboccipitobregmatic diameter and is thus the largest diameter of the fetal head, presents at the pelvic inlet. The head may engage but can descend only with significant molding. This molding and subsequent caput succedaneum over the forehead can become so extensive that identification of the brow by palpation is impossible late in labor. This may result in a missed diagnosis in a patient who presents later in active labor.

If the mentum is anterior and the forces of labor are directed toward the fetal occiput, flexing the head and pivoting the face under the pubic arch, there is conversion to a vertex occiput posterior position. If the occiput lies against the sacrum and the forces of labor are directed against the fetal mentum, the neck may extend further, leading to a face presentation.

The persistent brow presentation with subsequent delivery only occurs in cases of a large pelvis and/or a small infant. Women with gynecoid pelvis or multiparity may be given the option to labor; however, dysfunctional labor and cephalopelvic disproportion are more likely if this presentation persists.

Labor management of face and brow presentation requires close observation of labor progression because cephalopelvic disproportion, dysfunctional labor, and prolonged labor are much more common. As mentioned above, the trachelobregmatic or submentobregmatic diameters are larger than the suboccipitobregmatic diameter. Duration of labor with a face presentation is generally the same as duration of labor with a vertex presentation, although a prolonged labor may occur. As long as maternal or fetal compromise is not evident, labor with a face presentation may continue. [ 6 ] A persistent mentum posterior presentation is an indication for delivery by cesarean section.

Continuous electronic fetal heart rate monitoring is considered mandatory by many authors because of the increased incidence of abnormal fetal heart rate patterns and/or nonreassuring fetal heart rate patterns. [ 7 ] An internal fetal scalp electrode may be used, but very careful application of the electrode must be ensured. The mentum is the recommended site of application. Facial edema is common and can obscure the fetal facial anatomy and improper placement can lead to facial and ophthalmic injuries. Oxytocin can be used to augment labor using the same precautions as in a vertex presentation and the same criteria of assessment of uterine activity, adequacy of the pelvis, and reassuring fetal heart tracing.

Fetuses with face presentation can be delivered vaginally with overall success rates of 60-70%, while more than 20% of fetuses with face presentation require cesarean delivery. Cesarean delivery is performed for the usual obstetrical indications, including arrest of labor and nonreassuring fetal heart rate pattern.

Attempts to manually convert the face to vertex (Thom maneuver) or to rotate a posterior position to a more favorable anterior mentum position are rarely successful and are associated with high fetal morbidity and mortality and maternal morbidity, including cord prolapse, uterine rupture, and fetal cervical spine injury with neurological impairment. Given the availability and safety of cesarean delivery, internal rotation maneuvers are no longer justified unless cesarean section cannot be readily performed.

Internal podalic version and breech extraction are also no longer recommended in the modern management of the face presentation. [ 8 ]

Operative delivery with forceps must be approached with caution. Since engagement occurs when the face is at +2 position, forceps should only be applied to the face that has caused the perineum to bulge. Increased complications to both mother and fetus can occur [ 9 ] and operative delivery must be approached with caution or reserved when cesarean section is not readily available. Forceps may be used if the mentum is anterior. Although the landmarks are different, the application of any forceps is made as if the fetus were presenting directly in the occiput anterior position. The mouth substitutes for the posterior fontanelle, and the mentum substitutes for the occiput. Traction should be downward to maintain extension until the mentum passes under the symphysis, and then gradually elevated to allow the head to deliver by flexion. During delivery, hyperextension of the fetal head should be avoided.

As previously mentioned, the persistent brow presentation has a poor prognosis for vaginal delivery unless the fetus is small, premature, or the maternal pelvis is large. Expectant management is reasonable if labor is progressing well and the fetal well-being is assessed, as there can be spontaneous conversion to face or vertex presentation. The earlier in labor that brow presentation is diagnosed, the higher the likelihood of conversion. Minimal intervention during labor is recommended and some feel the use of oxytocin in the brow presentation is contraindicated.

The use of operative vaginal delivery or manual conversion of a brow to a more favorable presentation is contraindicated as the risks of perinatal morbidity and mortality are unacceptably high. Prolonged, dysfunctional, and arrest of labor are common, necessitating cesarean section delivery.

The incidence of perinatal morbidity and mortality and maternal morbidity has decreased due to the increased incidence of cesarean section delivery for malpresentation, including face and brow presentation.

Neonates delivered in the face presentation exhibit significant facial and skull edema, which usually resolves within 24-48 hours. Trauma during labor may cause tracheal and laryngeal edema immediately after delivery, which can result in neonatal respiratory distress. In addition, fetal anomalies or tumors, such as fetal goiters that may have contributed to fetal malpresentation, may make intubation difficult. Physicians with expertise in neonatal resuscitation should be present at delivery in the event that intubation is required. When a fetal anomaly has been previously diagnosed by ultrasonographic evaluation, the appropriate pediatric specialists should be consulted and informed at time of labor.

Bellussi F, Ghi T, Youssef A, et al. The use of intrapartum ultrasound to diagnose malpositions and cephalic malpresentations. Am J Obstet Gynecol . 2017 Dec. 217 (6):633-41. [QxMD MEDLINE Link] .

[Guideline] Ghi T, Eggebø T, Lees C, et al. ISUOG Practice Guidelines: intrapartum ultrasound. Ultrasound Obstet Gynecol . 2018 Jul. 52 (1):128-39. [QxMD MEDLINE Link] . [Full Text] .

Shaffer BL, Cheng YW, Vargas JE, Laros RK Jr, Caughey AB. Face presentation: predictors and delivery route. Am J Obstet Gynecol . 2006 May. 194(5):e10-2. [QxMD MEDLINE Link] .

Borell U, Fernstrom I. The mechanism of labour. Radiol Clin North Am . 1967 Apr. 5(1):73-85. [QxMD MEDLINE Link] .

Borell U, Fernstrom I. The mechanism of labour in face and brow presentation: a radiographic study. Acta Obstet Gynecol Scand . 1960. 39:626-44.

Gardberg M, Leonova Y, Laakkonen E. Malpresentations--impact on mode of delivery. Acta Obstet Gynecol Scand . 2011 May. 90(5):540-2. [QxMD MEDLINE Link] .

Collaris RJ, Oei SG. External cephalic version: a safe procedure? A systematic review of version-related risks. Acta Obstet Gynecol Scand . 2004 Jun. 83(6):511-8. [QxMD MEDLINE Link] .

Verspyck E, Bisson V, Gromez A, Resch B, Diguet A, Marpeau L. Prophylactic attempt at manual rotation in brow presentation at full dilatation. Acta Obstet Gynecol Scand . 2012 Nov. 91(11):1342-5. [QxMD MEDLINE Link] .

Johnson JH, Figueroa R, Garry D. Immediate maternal and neonatal effects of forceps and vacuum-assisted deliveries. Obstet Gynecol . 2004 Mar. 103(3):513-8. [QxMD MEDLINE Link] .

Benedetti TJ, Lowensohn RI, Truscott AM. Face presentation at term. Obstet Gynecol . 1980 Feb. 55(2):199-202. [QxMD MEDLINE Link] .

BROWNE AD, CARNEY D. OBSTETRICS IN GENERAL PRACTICE. MANAGEMENT OF MALPRESENTATIONS IN OBSTETRICS. Br Med J . 1964 May 16. 1(5393):1295-8. [QxMD MEDLINE Link] .

Campbell JM. Face presentation. Aust N Z J Obstet Gynaecol . 1965 Nov. 5(4):231-4. [QxMD MEDLINE Link] .

Contributor Information and Disclosures

Teresa Marino, MD Assistant Professor, Attending Physician, Division of Maternal-Fetal Medicine, Tufts Medical Center Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference Disclosure: Received salary from Medscape for employment. for: Medscape.

Carl V Smith, MD The Distinguished Chris J and Marie A Olson Chair of Obstetrics and Gynecology, Professor, Department of Obstetrics and Gynecology, Senior Associate Dean for Clinical Affairs, University of Nebraska Medical Center Carl V Smith, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists , American Institute of Ultrasound in Medicine , Association of Professors of Gynecology and Obstetrics , Central Association of Obstetricians and Gynecologists , Society for Maternal-Fetal Medicine , Council of University Chairs of Obstetrics and Gynecology , Nebraska Medical Association Disclosure: Nothing to disclose.

Chitra M Iyer, MD, Perinatologist, Obstetrix Medical Group, Fort Worth, Texas.

Chitra M Iyer, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists , Society of Maternal-Fetal Medicine .

Disclosure: Nothing to disclose.

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Breech Births

In the last weeks of pregnancy, a baby usually moves so his or her head is positioned to come out of the vagina first during birth. This is called a vertex presentation. A breech presentation occurs when the baby’s buttocks, feet, or both are positioned to come out first during birth. This happens in 3–4% of full-term births.

What are the different types of breech birth presentations?

• Complete breech: Here, the buttocks are pointing downward with the legs folded at the knees and feet near the buttocks.
• Frank breech: In this position, the baby’s buttocks are aimed at the birth canal with its legs sticking straight up in front of his or her body and the feet near the head.
• Footling breech: In this position, one or both of the baby’s feet point downward and will deliver before the rest of the body.

What causes a breech presentation?

The causes of breech presentations are not fully understood. However, the data show that breech birth is more common when:

• You have been pregnant before
• In pregnancies of multiples
• When there is a history of premature delivery
• When the uterus has too much or too little amniotic fluid
• When there is an abnormally shaped uterus or a uterus with abnormal growths, such as fibroids
• The placenta covers all or part of the opening of the uterus placenta previa

How is a breech presentation diagnosed?

A few weeks prior to the due date, the health care provider will place her hands on the mother’s lower abdomen to locate the baby’s head, back, and buttocks. If it appears that the baby might be in a breech position, they can use ultrasound or pelvic exam to confirm the position. Special x-rays can also be used to determine the baby’s position and the size of the pelvis to determine if a vaginal delivery of a breech baby can be safely attempted.

Can a breech presentation mean something is wrong?

Even though most breech babies are born healthy, there is a slightly elevated risk for certain problems. Birth defects are slightly more common in breech babies and the defect might be the reason that the baby failed to move into the right position prior to delivery.

Can a breech presentation be changed?

It is preferable to try to turn a breech baby between the 32nd and 37th weeks of pregnancy . The methods of turning a baby will vary and the success rate for each method can also vary. It is best to discuss the options with the health care provider to see which method she recommends.

Medical Techniques

External Cephalic Version (EVC)  is a non-surgical technique to move the baby in the uterus. In this procedure, a medication is given to help relax the uterus. There might also be the use of an ultrasound to determine the position of the baby, the location of the placenta and the amount of amniotic fluid in the uterus.

Gentle pushing on the lower abdomen can turn the baby into the head-down position. Throughout the external version the baby’s heartbeat will be closely monitored so that if a problem develops, the health care provider will immediately stop the procedure. ECV usually is done near a delivery room so if a problem occurs, a cesarean delivery can be performed quickly. The external version has a high success rate and can be considered if you have had a previous cesarean delivery.

ECV will not be tried if:

• You are carrying more than one fetus
• There are concerns about the health of the fetus
• You have certain abnormalities of the reproductive system
• The placenta is in the wrong place
• The placenta has come away from the wall of the uterus ( placental abruption )

Complications of EVC include:

• Prelabor rupture of membranes
• Changes in the fetus’s heart rate
• Placental abruption
• Preterm labor

Vaginal delivery versus cesarean for breech birth?

Most health care providers do not believe in attempting a vaginal delivery for a breech position. However, some will delay making a final decision until the woman is in labor. The following conditions are considered necessary in order to attempt a vaginal birth:

• The baby is full-term and in the frank breech presentation
• The baby does not show signs of distress while its heart rate is closely monitored.
• The process of labor is smooth and steady with the cervix widening as the baby descends.
• The health care provider estimates that the baby is not too big or the mother’s pelvis too narrow for the baby to pass safely through the birth canal.
• Anesthesia is available and a cesarean delivery possible on short notice

What are the risks and complications of a vaginal delivery?

In a breech birth, the baby’s head is the last part of its body to emerge making it more difficult to ease it through the birth canal. Sometimes forceps are used to guide the baby’s head out of the birth canal. Another potential problem is cord prolapse . In this situation the umbilical cord is squeezed as the baby moves toward the birth canal, thus slowing the baby’s supply of oxygen and blood. In a vaginal breech delivery, electronic fetal monitoring will be used to monitor the baby’s heartbeat throughout the course of labor. Cesarean delivery may be an option if signs develop that the baby may be in distress.

When is a cesarean delivery used with a breech presentation?

Most health care providers recommend a cesarean delivery for all babies in a breech position, especially babies that are premature. Since premature babies are small and more fragile, and because the head of a premature baby is relatively larger in proportion to its body, the baby is unlikely to stretch the cervix as much as a full-term baby. This means that there might be less room for the head to emerge.

Want to Know More?

• Creating Your Birth Plan
• Labor & Birth Terms to Know
• Cesarean Birth After Care

Compiled using information from the following sources:

• ACOG: If Your Baby is Breech
• William’s Obstetrics Twenty-Second Ed. Cunningham, F. Gary, et al, Ch. 24.
• Danforth’s Obstetrics and Gynecology Ninth Ed. Scott, James R., et al, Ch. 21.

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Labour and Delivery Care Module: 8. Abnormal Presentations and Multiple Pregnancies

Study session 8  abnormal presentations and multiple pregnancies, introduction.

In previous study sessions of this module, you have been introduced to the definitions, signs, symptoms and stages of normal labour, and about the ‘normal’ vertex presentation of the fetus during delivery. In this study session, you will learn about the most common abnormal presentations (breech, shoulder, face or brow), their diagnostic criteria and the required actions you need to take to prevent complications developing during labour. Taking prompt action may save the life of the mother and her baby if the delivery becomes obstructed because the baby is in an abnormal presentation. We will also tell you about twin births and the complications that may result if the two babies become ‘locked’ together, preventing either of them from being born.

Learning Outcomes for Study Session 8

After studying this session, you should be able to:

8.1  Define and use correctly all of the key words printed in bold . (SAQs 8.1 and 8.2)

8.2  Describe how you would identify a fetus in the vertex presentation and distinguish this from common malpresentations and malpositions. (SAQs 8.1 and 8.2)

8.3  Describe the causes and complications for the fetus and the mother of fetal malpresentation during full term labour. (SAQ 8.3)

8.4  Describe how you would identify a multiple pregnancy and the complications that may arise. (SAQ 8.4)

8.5  Explain when and how you would refer a woman in labour due to abnormal fetal presentation or multiple pregnancy. (SAQ 8.4)

8.1  Normal and abnormal presentations

8.1.1  vertex presentation.

In about 95% of deliveries, the part of the fetus which arrives first at the mother’s pelvic brim is the highest part of the fetal head, which is called the vertex (Figure 8.1). This presentation is called the vertex presentation . Notice that the baby’s chin is tucked down towards its chest, so that the vertex is the leading part entering the mother’s pelvis. The baby’s head is said to be ‘well-flexed’ in this position.

During early pregnancy, the baby is the other way up — with its bottom pointing down towards the mother’s cervix — which is called the breech presentation . This is because during its early development, the head of the fetus is bigger than its buttocks; so in the majority of cases, the head occupies the widest cavity, i.e. the fundus (rounded top) of the uterus. As the fetus grows larger, the buttocks become bigger than the head and the baby spontaneously reverses its position, so its buttocks occupy the fundus. In short, in early pregnancy, the majority of fetuses are in the breech presentation and later in pregnancy most of them make a spontaneous transition to the vertex presentation.

8.1.2  Malpresentations

You will learn about obstructed labour in Study Session 9.

When the baby presents itself in the mother’s pelvis in any position other than the vertex presentation, this is termed an abnormal presentation, or m alpresentation . The reason for referring to this as ‘abnormal’ is because it is associated with a much higher risk of obstruction and other birth complications than the vertex presentation. The most common types of malpresentation are termed breech, shoulder, face or brow. We will discuss each of these in turn later. Notice that the baby can be ‘head-down’ but in an abnormal presentation, as in face or brow presentations, when the baby’s face or forehead (brow) is the presenting part.

8.1.3  Malposition

Although it may not be so easy for you to identify this, the baby can also be in an abnormal position even when it is in the vertex presentation. In a normal delivery, when the baby’s head has engaged in the mother’s pelvis, the back of the baby’s skull (the occiput ) points towards the front of the mother’s pelvis (the pubic symphysis ), where the two pubic bones are fused together. This orientation of the fetal skull is called the occipito-anterior position (Figure 8.2a). If the occiput (back) of the fetal skull is towards the mother’s back, this occipito-posterior position (Figure 8.2b) is a vertex malposition , because it is more difficult for the baby to be born in this orientation. The good thing is that more than 90% of babies in vertex malpositions undergo rotation to the occipito-anterior position and are delivered normally.

You learned the directional positions: anterior/in front of and posterior/behind or in the back of, in the Antenatal Care Module, Part 1, Study Session 3.

Note that the fetal skull can also be tilted to the left or to the right in either the occipito-anterior or occipito-posterior positions.

8.2  Causes and consequences of malpresentations and malpositions

In the majority of individual cases it may not be possible to identify what caused the baby to be in an abnormal presentation or position during delivery. However, the general conditions that are thought to increase the risk of malpresentation or malposition are listed below:

Multiple pregnancy is the subject of Section 8.7 of this study session. You learned about placenta previa in the Antenatal Care Module, Study Session 21.

• Abnormally increased or decreased amount of amniotic fluid
• A tumour (abnormal tissue growth) in the uterus preventing the spontaneous inversion of the fetus from breech to vertex presentation during late pregnancy
• Abnormal shape of the pelvis
• Laxity (slackness) of muscular layer in the walls of the uterus
• Multiple pregnancy (more than one baby in the uterus)
• Placenta previa (placenta partly or completely covering the cervical opening).

If the baby presents at the dilating cervix in an abnormal presentation or malposition, it will more difficult (and may be impossible) for it to complete the seven cardinal movements that you learned about in Study Sessions 3 and 5. As a result, birth is more difficult and there is an increased risk of complications, including:

You learned about PROM in Study Session 17 of the Antenatal Care Module, Part 2.

• Premature rupture of the fetal membranes (PROM)
• Premature labour
• Slow, erratic, short-lived contractions
• Uncoordinated and extremely painful contractions, with slow or no progress of labour
• Prolonged and obstructed labour, leading to a ruptured uterus (see Study Sessions 9 and 10 of this Module)
• Postpartum haemorrhage (see Study Session 11)
• Fetal and maternal distress, which may lead to the death of the baby and/or the mother.

With these complications in mind, we now turn your attention to the commonest types of malpresentation and how to recognise them.

8.3  Breech presentation

In a b reech presentation , the fetus lies with its buttocks in the lower part of the uterus, and its buttocks and/or the feet are the presenting parts during delivery. Breech presentation occurs on average in 3–4% of deliveries after 34 weeks of pregnancy.

When is the breech position the normal position for the fetus?

During early pregnancy the baby’s bottom points down towards the mother’s cervix, and its head (the largest part of the fetus at this stage of development) occupies the fundus (rounded top) of the uterus, which is the widest part of the uterine cavity.

8.3.1  Causes of breech presentation

You can see a transverse lie in Figure 8.7 later in this study session.

In the majority of cases there is no obvious reason why the fetus should present by the breech at full term. In practice, what is commonly observed is the association of breech presentation at delivery with a transverse lie earlier in the pregnancy, i.e. the fetus lies sideways across the mother’s abdomen, facing a sideways implanted placenta. It is thought that when the placenta is in front of the baby’s face, it may obstruct the normal process of inversion, when the baby turns head-down as it gets bigger during the pregnancy. As a result, the fetus turns in the other direction and ends in the breech presentation. Some other circumstances that are thought to favour a breech presentation during labour include:

• Premature labour, beginning before the baby undergoes spontanous inversion from breech to vertex presentation
• Multiple pregnancy, preventing the normal inversion of one or both babies
• Polyhydramnios: excessive amount of amniotic fluid, which makes it more difficult for the fetal head to ‘engage’ with the mother’s cervix (polyhydramnios is pronounced ‘poll-ee-hy-dram-nee-oss’. Hydrocephaly is pronounced ‘hy-droh-keff-all-ee’)
• Hydrocephaly (‘water on the brain’) i.e. an abnormally large fetal head due to excessive accumulation of fluid around the brain
• Placenta praevia
• Breech delivery in the previous pregnancy
• Abnormal formation of the uterus.

8.3.2  Diagnosis of breech presentation

On abdominal palpation the fetal head is found above the mother’s umbilicus as a hard, smooth, rounded mass, which gently ‘ballots’ (can be rocked) between your hands.

Why do you think a mass that ‘ballots’ high up in the abdomen is a sign of breech presentation? (You learned about this in Study Session 11 of the Antenatal Care Module.)

The baby’s head can ‘rock’ a little bit because of the flexibility of the baby’s neck, so if there is a rounded, ballotable mass above the mother’s umbilicus it is very likely to be the baby’s head. If the baby was ‘bottom-up’ (vertex presentation) the whole of its back will move of you try to rock the fetal parts at the fundus (Figure 8.3).

Once the fetus has engaged and labour has begun, the breech baby’s buttocks can be felt as soft and irregular on vaginal examination. They feel very different to the relatively hard rounded mass of the fetal skull in a vertex presentation. When the fetal membranes rupture, the buttocks and/or feet can be felt more clearly. The baby’s anus may be felt and fresh thick, dark meconium may be seen on your examining finger. If the baby’s legs are extended, you may be able to feel the external genitalia and even tell the sex of the baby before it is born.

8.3.3  Types of breech presentation

There are three types of breech presentation, as illustrated in Figure 8.4. They are:

• Complete breech is characterised by flexion of the legs at both hips and knee joints, so the legs are bent underneath the baby.
• Frank breech is the commonest type of breech presentation, and is characterised by flexion at the hip joints and extension at the knee joints, so both the baby’s legs point straight upwards.
• Footling breech is when one or both legs are extended at the hip and knee joint and the baby presents ‘foot first’.

8.3.4  Risks of breech presentation

Regardless of the type of breech presentation, there are significant associated risks to the baby. They include:

• The fetal head gets stuck (arrested) before delivery
• Labour becomes obstructed when the fetus is disproportionately large for the size of the maternal pelvis
• Cord prolapse may occur, i.e. the umbilical cord is pushed out ahead of the baby and may get compressed against the wall of the cervix or vagina
• Premature separation of the placenta (placental abruption)
• Birth injury to the baby, e.g. fracture of the arms or legs, nerve damage, trauma to the internal organs, spinal cord damage, etc.

A breech birth may also result in trauma to the mother’s birth canal or external genitalia through being overstretched by the poorly fitting fetal parts.

Cord prolapse in a normal (vertex) presentation was illustrated in Study Session 17 of the Antenatal Care Module, and placental abruption was covered in Study Session 21.

What will be the effect on the baby if it gets stuck, the labour is obstructed, the cord prolapses, or placental abruption occurs?

The result will be hypoxia , i.e. it will be deprived of oxygen, and may suffer permanent brain damage or die.

You learned about the causes and consequences of hypoxia in the Antenatal Care Module.

8.4  Face presentation

Face presentation occurs when the baby’s neck is so completely extended (bent backwards) that the occiput at the back of the fetal skull touches the baby’s own spine (see Figure 8.5). In this position, the baby’s face will present to you during delivery.

Refer the mother if a baby in the chin posterior face presentation does not rotate and the labour is prolonged.

The incidence of face presentation is about 1 in 500 pregnancies in full term labours. In Figure 8.5, you can see how flexed the head is at the neck. Babies who present in the ‘chin posterior’ position (on the right in Figure 8.5) usually rotate spontaneously during labour, and assume the ‘chin anterior’ position, which makes it easier for them to be born. However, they are unlikely to be delivered vaginally if they fail to undergo spontaneous rotation to the chin anterior position, because the baby’s chin usually gets stuck against the mother’s sacrum (the bony prominence at the back of her pelvis). A baby in this position will have to be delivered by caesarean surgery.

8.4.1  Causes of face presentation

The causes of face presentation are similar to those already described for breech births:

• Laxity (slackness) of the uterus after many previous full-term pregnancies
• Multiple pregnancy
• Polyhydramnios (excessive amniotic fluid)
• Congenital abnormality of the fetus (e.g. anencephaly, which means no or incomplete skull bones)
• Abnormal shape of the mother’s pelvis.

8.4.2  Diagnosis of face presentation

Face presentation may not be easily detected by abdominal palpation, especially if the chin is in the posterior position. On abdominal examination, you may feel irregular shapes, formed because the fetal spine is curved in an ‘S’ shape. However, on vaginal examination, you can detect face presentation because:

• The presenting part will be high, soft and irregular.
• When the cervix is sufficiently dilated, you may be able to feel parts of the face, such as the orbital ridges above the eyes, the nose or mouth, gums, or bony chin.
• If the membranes are ruptured, the baby may suck your examining finger!

But as labour progresses, the baby’s face becomes o edematous (swollen with fluid), making it more difficult to distinguish from the soft shape you will feel in a breech presentation.

8.4.3  Complications of face presentation

Complications for the fetus include:

• Obstructed labour and ruptured uterus
• Cord prolapse
• Facial bruising
• Cerebral haemorrhage (bleeding inside the fetal skull).

8.5  Brow presentation

In brow presentation , the baby’s head is only partially extended at the neck (compare this with face presentation), so its brow (forehead) is the presenting part (Figure 8.6). This presentation is rare, with an incidence of 1 in 1000 deliveries at full term.

8.5.1  Possible causes of brow presentation

You have seen all of these factors before, as causes of other malpresentations:

• Lax uterus due to repeated full term pregnancy
• Polyhydramnios

8.5.2  Diagnosis of brow presentation

Brow presentation is not usually detected before the onset of labour, except by very experienced birth attendants. On abdominal examination, the head is high in the mother’s abdomen, appears unduly large and does not descend into the pelvis, despite good uterine contractions. On vaginal examination, the presenting part is high and may be difficult to reach. You may be able to feel the root of the nose, eyes, but not the mouth, tip of the nose or chin. You may also feel the anterior fontanel, but a large caput (swelling) towards the front of the fetal skull may mask this landmark if the woman has been in labour for some hours.

Recall the appearance of a normal caput over the posterior fontanel shown in Figure 4.4 earlier in this Module.

8.5.3  Complications of brow presentation

The complications of brow presentation are much the same as for other malpresentations:

• Cerebral haemorrhage.

Which are you more likely to encounter — face or brow presentations?

Face presentation, which occurs in 1 in 500 full term labours. Brow presentation is more rare, at 1 in 1,000 full term labours.

8.6  Shoulder presentation

Shoulder presentation is rare at full term, but may occur when the fetus lies transversely across the uterus (Figure 8.7), if it stopped part-way through spontaneous inversion from breech to vertex, or it may lie transversely from early pregnancy. If the baby lies facing upwards, its back may be the presenting part; if facing downwards its hand may emerge through the cervix. A baby in the transverse position cannot be born through the vagina and the labour will be obstructed. Refer babies in shoulder presentation urgently.

8.6.1  Causes of shoulder presentation

Causes of shoulder presentation could be maternal or fetal factors.

Maternal factors include:

• Lax abdominal and uterine muscles: most often after several previous pregnancies
• Uterine abnormality
• Contracted (abnormally narrow) pelvis.

Fetal factors include:

• Preterm labour
• Placenta previa.

What do ‘placenta previa’ and ‘polyhydramnios’ indicate?

Placenta previa is when the placenta is partly or completely covering the cervical opening. Polyhydramnios is an excess of amniotic fluid. They are both potential causes of malpresentation.

8.6.2  Diagnosis of shoulder presentation

On abdominal palpation, the uterus appears broader and the height of the fundus is less than expected for the period of gestation, because the fundus is not occupied by either the baby’s head or buttocks. You can usually feel the head on one side of the mother’s abdomen. On vaginal examination, in early labour, the presenting part may not be felt, but when the labour is well progressed, you may feel the baby’s ribs. When the shoulder enters the pelvic brim, the baby’s arm may prolapse and become visible outside the vagina.

8.6.3  Complications of shoulder presentation

Complications include:

• Trauma to a prolapsed arm
• Fetal hypoxia and death.

Remember that a shoulder presentation means the baby cannot be born through the vagina; if you detect it in a woman who is already in labour, refer her urgently to a higher health facility.

8.7  Multiple pregnancy

In this section, we turn to the subject of multiple pregnancy , when there is more than one fetus in the uterus. More than 95% of multiple pregnancies are twins (two fetuses), but there can also be triplets (three fetuses), quadruplets (four fetuses), quintuplets (five fetuses), and other higher order multiples with a declining chance of occurrence. The spontaneous occurrence of twins varies by country : it is lowest in East Asia n countries like Japan and China (1 out of 1000 pregnancies are fraternal or non-identical twins), and highest in black Africans , particularly in Nigeria , where 1 in 20 pr egnancies are fraternal twins. In general, compared to single babies, multiple pregnancies are highly associated with early pregnancy loss and high perinatal mortality, mainly due to prematurity.

8.7.1  Types of twin pregnancy

Twins may be identical (monozygotic) or non-identical and fraternal (dizigotic). Monozygotic twins develop from a single fertilised ovum (the zygote), so they are always the same sex and they share the same placenta . By contrast, dizygotic twins develop from two different zygotes, so they can have the same or different sex, and they have separate placenta s . Figure 8.8 shows the types of twin pregnancy and the processes by which they are formed.

8.7.2  Diagnosis of twin pregnancy

On abdominal examination you may notice that:

• The size of the uterus is larger than the expected for the period for gestation.
• The uterus looks round and broad, and fetal movement may be seen over a large area. (The shape of the uterus at term in a singleton pregnancy in the vertex presentation appears heart-shaped rounder at the top and narrower at the bottom.)
• Two heads can be felt.
• Two fetal heart beats may be heard if two people listen at the same time, and they can detect at least 10 beats different (Figure 8.6).
• Ultrasound examination can make an absolute diagnosis of twin pregnancy.

8.7.3  Consequences of twin pregnancy

Women who are pregnant with twins are more prone to suffer with the minor disorders of pregnancy, like morning sickness, nausea and heartburn. Twin pregnancy is one cause of hyperemesis gravidarum (persistent, severe nausea and vomiting). Mothers of twins are also more at risk of developing iron and folate-deficiency anaemia during pregnancy.

Can you suggest why anaemia is a greater risk in multiple pregnancies?

The mother has to supply the nutrients to feed two (or more) babies; if she is not getting enough iron and folate in her diet, or through supplements, she will become anaemic.

Other complications include the following:

• Pregnancy-related hypertensive disorders like pre-eclampsia and eclampsia are more common in twin pregnancies.
• Pressure symptoms may occur in late pregnancy due to the increased weight and size of the uterus.
• Labour often occurs spontaneously before term, with p remature delivery or premature rupture of membranes (PROM) .
• Respiratory deficit ( shortness of breath, because of fast growing uterus) is another common problem.

Twin babies may be small in comparison to their gestational age and more prone to the complications associated with low birth weight (increased vulnerability to infection, losing heat, difficulty breastfeeding).

You will learn about low birth weight babies in detail in the Postnatal Care Module.

• Malpresentation is more common in twin pregnancies, and they may also be ‘locked’ at the neck with one twin in the vertex presentation and the other in breech. The risks associated with malpresentations already described also apply: prolapsed cord, poor uterine contraction, prolonged or obstructed labour, postpartum haemorrhage, and fetal hypoxia and death.
• Conjoined twins (fused twins, joined at the head, chest, or abdomen, or through the back) may also rarely occur.

8.8  Management of women with malpresentation or multiple pregnancy

As you have seen in this study session, any presentation other than vertex has its own dangers for the mother and baby. For this reason, all women who develop abnormal presentation or multiple pregnancy should ideally have skilled care by senior health professionals in a health facility where there is a comprehensive emergency obstetric service. Early detection and referral of a woman in any of these situations can save her life and that of her baby.

What can you do to reduce the risks arising from malpresentation or multiple pregnancy in women in your care?

During focused antenatal care of the pregnant women in your community, at every visit after 36 weeks of gestation you should check for the presence of abnormal fetal presentation. If you detect abnormal presentation or multiple pregnancy, you should refer the woman before the onset of labour.

Summary of Study Session 8

In Study Session 8, you learned that:

• During early pregnancy, babies are naturally in the breech position, but in 95% of cases they spontaneously reverse into the vertex presentation before labour begins.
• Malpresentation or malposition of the fetus at full term increases the risk of obstructed labour and other birth complications.
• Common causes of malpresentations/malpositions include: excess amniotic fluid, abnormal shape and size of the pelvis; uterine tumour; placenta praevia; slackness of uterine muscles (after many previous pregnancies); or multiple pregnancy.
• Common complications include: premature rupture of membranes, premature labour, prolonged/obstructed labour; ruptured uterus; postpartum haemorrhage; fetal and maternal distress which may lead to death.
• Vertex malposition is when the fetal head is in the occipito-posterior position — i.e. the back of the fetal skull is towards the mother’s back instead of pointing towards the front of the mother’s pelvis. 90% of vertex malpositions rotate and deliver normally.
• Breech presentation (complete, frank or footling) is when the baby’s buttocks present during labour. It occurs in 3–4% of labours after 34 weeks of pregnancy and may lead to obstructed labour, cord prolapse, hypoxia, premature separation of the placenta, birth injury to the baby or to the birth canal.
• Face presentation is when the fetal head is bent so far backwards that the face presents during labour. It occurs in about 1 in 500 full term labours. ‘Chin posterior’ face presentations usually rotate spontaneously to the ‘chin anterior’ position and deliver normally. If rotation does not occur, a caesarean delivery is likely to be necessary.
• Brow presentation is when the baby’s forehead is the presenting part. It occurs in about 1 in 1000 full term labours and is difficult to detect before the onset of labour. Caesarean delivery is likely to be necessary.
• Shoulder presentation occurs when the fetal lie during labour is transverse. Once labour is well progressed, vaginal examination may feel the baby’s ribs, and an arm may sometimes prolapse. Caesarean delivery is always required unless a doctor or midwife can turn the baby head-down.
• Multiple pregnancies are always at high risk of malpresentation. Mothers need greater antenatal care, and twins are more prone to complications associated with low birth weight and prematurity.
• Any presentation other than vertex after 34 weeks of gestation is considered as high risk to the mother and to her baby. Do not attempt to turn a malpresenting or malpositioned baby! Refer the mother for emergency obstetric care.

Self-Assessment Questions (SAQs) for Study Session 8

Now that you have completed this study session, you can assess how well you have achieved its Learning Outcomes by answering the following questions. Write your answers in your Study Diary and discuss them with your Tutor at the next Study Support Meeting. You can check your answers with the Notes on the Self-Assessment Questions at the end of this Module.

SAQ 8.1 (tests Learning Outcomes 8.1, 8.2 and 8.4)

Which of the following definitions are true and which are false? Write down the correct definition for any which you think are false.

A  Fundus — the ‘rounded top’ and widest cavity of the uterus.

B  Complete breech — where the legs are bent at both hips and knee joints and are folded underneath the baby.

C  Frank breech — where the breech is so difficult to treat that you have to be very frank and open with the mother about the difficulties she will face in the birth.

D  Footling breech — when one or both legs are extended so that the baby presents ‘foot first’.

E  Hypoxia — the baby gets too much oxygen.

F  Multiple pregnancy — when a mother has had many babies previously.

G  Monozygotic twins — develop from a single fertilised ovum (the zygote). They can be different sexes but they share the same placenta.

H  Dizygotic twins — develop from two zygotes. They have separate placentas, and can be of the same sex or different sexes.

A is true.  The fundus is the ‘rounded top’ and widest cavity of the uterus.

B is true.  Complete breech is where the legs are bent at both hips and knee joints and are folded underneath the baby.

C is false . A frank breech is the most common type of breech presentation and is when the baby’s legs point straight upwards (see Figure 8.4).

D is true.   A footling breech is when one or both legs are extended so that the baby presents ‘foot first’.

E is false .  Hypoxia is when the baby is deprived of oxygen and risks permanent brain damage or death.

F is false.   Multiple pregnancy is when there is more than one fetus in the uterus.

G is false.   Monozygotic twins develop from a single fertilised ovum (the zygote), and they are always the same sex , as well as sharing the same placenta.

H is true.  Dizygotic twins develop from two zygotes, have separate placentas, and can be of the same or different sexes.

SAQ 8.2 (tests Learning Outcomes 8.1 and 8.2)

What are the main differences between normal and abnormal fetal presentations? Use the correct medical terms in bold in your explanation.

In a normal presentation, the vertex (the highest part of the fetal head) arrives first at the mother’s pelvic brim, with the occiput (the back of the baby’s skull) pointing towards the front of the mother’s pelvis (the pubic symphysis ).

Abnormal presentations are when there is either a vertex malposition (the occiput of the fetal skull points towards the mother’s back instead towards of the pubic symphysis), or a malpresentation (when anything other than the vertex is presenting): e.g. breech presentation (buttocks first); face presentation (face first); brow presentation (forehead first); and shoulder presentation (transverse fetal).

SAQ 8.3 (tests Learning Outcomes 8.3 and 8.5)

• a. List the common complications of malpresentations or malposition of the fetus at full term.
• b. What action should you take if you identify that the fetus is presenting abnormally and labour has not yet begun?
• c. What should you not attempt to do?
• a. The common complications of malpresentation or malposition of the fetus at full term include: premature rupture of membranes, premature labour, prolonged/obstructed labour; ruptured uterus; postpartum haemorrhage; fetal and maternal distress which may lead to death.
• b. You should refer the mother to a higher health facility – she may need emergency obstetric care.
• c. You should not attempt to turn the baby by hand. This should only be attempted by a specially trained doctor or midwife and should only be done at a health facility.

SAQ 8.4 (tests Learning Outcomes 8.4 and 8.5)

A pregnant woman moves into your village who is already at 37 weeks gestation. You haven’t seen her before. She tells you that she gave birth to twins three years ago and wants to know if she is having twins again this time.

• a. How would you check this?
• b. If you diagnose twins, what would you do to reduce the risks during labour and delivery?
• Is the uterus larger than expected for the period of gestation?
• What is its shape – is it round (indicative of twins) or heart-shaped (as in a singleton pregnancy)?
• Can you feel more than one head?
• Can you hear two fetal heartbeats (two people listening at the same time) with at least 10 beats difference?
• If there is access to a higher health facility, and you are still not sure, try and get the woman to it for an ultrasound scan.
• Be extra careful to check that the mother is not anaemic.
• Encourage her to rest and put her feet up to reduce the risk of increased blood pressure or swelling in her legs and feet.
• Be alert to the increased risk of pre-eclampsia.
• Expect her to go into labour before term, and be ready to get her to the health facility before she goes into labour, going with her if at all possible.
• Get in early touch with that health facility to warn them to expect a referral from you.
• Make sure that transport is ready to take her to a health facility when needed.

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7.10 Brow presentation

Brow presentation constitutes an absolute foeto-pelvic disproportion, and vaginal delivery is impossible (except with preterm birth or extremely low birth weight).

This is an obstetric emergency, because labour is obstructed and there is a risk of uterine rupture and foetal distress.

7.10.1 Diagnosis

• Head is high; as with a face presentation, there is a cleft between the head and back, but it is less marked.
• the chin (it is not a face presentation),
• the posterior fontanelle (it is not a vertex presentation).

Figures 7.9 - Brow presentation

Any mobile presenting part can subsequently flex. The diagnosis of brow presentation is, therefore, not made until after the membranes have ruptured and the head has begun to engage in a fixed presentation. Some brow presentations will spontaneously convert to a vertex or, more rarely, a face presentation.

During delivery, the presenting part is slow to descend: the brow is becoming impacted.

7.10.2 Management

Foetus alive.

• Perform a caesarean section. When performing the caesarean section, an assistant must be ready to free the head by pushing it upward with a hand in the vagina.
• Convert the brow presentation to a face presentation: between contractions, insert the fingers through the cervix and move the head, encouraging extension (Figures 7.10).
• Attempt internal podalic version ( Section 7.9 ).

Both these manoeuvres pose a significant risk of uterine rupture. Vacuum extraction, forceps and symphysiotomy are contra-indicated.

Foetus dead

Perform an embryotomy if the cervix is sufficiently dilated (Chapter 9, Section 9.7 ) otherwise, a caesarean section.

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Female Anatomy

Diagrams of the inside and outside of female body parts

• Breast Anatomy

Frequently Asked Questions

Female anatomy includes the internal and external structures of the reproductive and urinary systems. Reproductive anatomy plays a role in sexual pleasure, getting pregnant , and breastfeeding . The urinary system helps rid the body of toxins through urination (peeing). 

The main parts of the female anatomy can be broken up into outside (external) and inside (internal) parts.

External female anatomy includes:

• Vaginal opening

*Collectively referred to as the the Vulva

Internal female anatomy includes the:

• Fallopian tubes
• Bartholin glands and Skene's glands

Female breasts have both internal and external parts.

This article discusses the location and function of the various parts of the female anatomy.

Note: Some people are born with internal or external structures that are ambiguous or characteristic of both male and female anatomy, which we do not cover here.

A Note on Gender and Sex Terminology

Verywell Health acknowledges that  sex and gender  are related concepts, but they are not the same. To reflect our sources accurately, this article uses terms like “female,” “male,” “woman,” and “man” as the sources use them.

The word “female” is used throughout this article to refer to anatomical reproductive classification and people assigned female at birth based on visible reproductive organs. Some people who identify as women do not have the anatomy depicted, while others who have the anatomy depicted do not identify as women and may use different terminology to refer to their anatomy.

Female Anatomy Diagram

This female anatomy diagram is a good place to start if you're unsure of exactly where parts of the female reproductive and urinary systems are in comparison to one another.

The following sections go into detail about these and other parts of the female anatomy.

External Female Anatomy

The vulva is made up of the structures outside the vaginal opening. These external structures include:

• Mons pubis : The mons pubis is the rounded, fleshy area on the front of the pelvic bone (the lower belly area) where pubic hair usually grows. 
• Labia majora : The labia majora are the fleshy outer folds of protective skin located on each side of the vaginal opening. They cover and protect the more delicate external genital organs. "Labia" is the Latin word for lips. The labia majora is often referred to as the outer lips.
• Labia minora : The labia minora are skinfolds that are just inside the labia majora. In some people, the labia minora extends past the labia majora. 
• Clitoris : The clitoris sits at the top of the vulva, above the urethral opening. A fold of skin called the clitoral hood covers most of the clitoris, leaving only the tip (nub) visible. The rest of the clitoris is a spongy shaft that goes back several inches inside the body.  
• Urethral opening : The urethra is the tube that carries urine from the bladder to the outside of the body. Its opening is located below the clitoris, directly above the vaginal opening. 
• The vaginal opening : The vaginal opening is located between the urethra and the anus.
• Bartholin glands : Bartholin glands sit on both sides inside the vaginal opening. They release secretions that lubricate the vagina to make sexual intercourse more comfortable.
• Skene's glands : The Skene's glands are located on either side of the urethra. They lubricate the urethral opening. Skene’s glands are sometimes called "the female prostate." Some scientists think these glands are responsible for "female ejaculation" or " squirting " during sexual arousal.

Functions of the Vaginal Opening

The vaginal opening is where:

• Menstrual blood leaves the body
• Sexual intercourse for reproduction and/or pleasure occurs
• A baby exits the body during vaginal birth 

The Internal Female Anatomy

The rest of the female genitalia are inside the vaginal opening. These internal structures of female anatomy include the:

• Vagina : The vagina is a muscular canal that connects the cervix to the outside of the body. Parts of the vagina are made of collagen and elastin, which help it expand during sexual stimulation and childbirth.
• Cervix : The cervix is the end of the uterus that sits within the top of the vagina. It may play a role in lubrication. Contact between the penis and cervix during sexual intercourse may be pleasurable for some but painful for others. During childbirth, the cervix dilates so the baby can move out of the uterus, into the vagina, and out of the body.
• Uterus : The uterus is located in the lower belly area between the hips (pelvis), through the vagina just past the cervix. It's also called the womb. The uterus is where a fetus develops during pregnancy. The uterus has three layers. The middle muscular layer is one of the strongest muscles in the body.
• Ovaries : The ovaries are small organs located on both sides of the pelvis. They play an important role in female hormone production and produce eggs during ovulation.
• Fallopian tubes : The fallopian tubes connect the ovaries to the uterus on each side. Hairlike structures called cilia guide the egg from the ovary to the uterus.
• Hymen : The hymen is a thin tissue that sits at the vaginal opening. It has no known biological function. The hymen becomes more elastic with age and breaks or ruptures at some point in a person's life. While sexual activity is one way this can happen, a broken hymen is not evidence of sexual activity.

Female Breast Anatomy 

The breast contains multiple structures within it, including:

• Adipose tissue : Each breast has fatty ( adipose ) tissue that is used to store extra energy.
• Lobules : There are 15 to 20 sections called lobules in the fatty tissue. They are attached to ducts that can produce milk. 
• Milk ducts : The milk ducts are internal structures that go to the areola and nipple, which are the outer portion of the breast. 
• Areola and nipples : The areola is the darker area on the outside of the breast that surrounds the nipple in the center.

Functions of Female Body Parts

The various parts of the female anatomy serve different functions, which include hormone production, sexual arousal, conception, and pregnancy.

Hormonal Changes

Estrogen and progesterone are the primary female hormones produced by the reproductive system. Hormone production increases at puberty, giving a person the ability to menstruate and conceive.

Female hormones also promote vaginal lubrication and increase sexual desire.

Sexual Arousal

Female anatomy is designed for both intimacy and conception. The vulva, vagina, and breasts are sensitive to being touched, which helps with sexual arousal.

The role of the clitoris is just for sexual pleasure. It has many sensitive nerve endings that respond to touch. When a person is aroused, the clitoris tissue gets bigger—just like erectile swelling in people with a penis.

Conception and Pregnancy 

During ovulation, an ovary releases an egg that travels to a fallopian tube, where it stays for a brief period. If a sperm from semen introduced during penile-vaginal intercourse swims to the egg and joins it, fertilization (conception) occurs.

This creates a zygote, which evolves further as it finds its way to the uterus, where it implants. This is what develops into an embryo. Fertilization can happen hours or days after sexual intercourse.

If the egg is not fertilized and pregnancy does not occur, the uterine lining sheds instead. This part of the menstrual cycle is a person's period. Most people who menstruate have a cycle every 28 to 31 days, in the absence of pregnancy, but this varies depending on how often they ovulate.

Understanding female anatomy inside and out can help you prepare for changes during puberty, adulthood, pregnancy, and menopause. It can also help you better understand a related condition you may be diagnosed with.

The internal and external structures of the female anatomy, including the vagina, vulva, uterus, and clitoris, play important roles in sexual arousal, intercourse, conception, pregnancy, and childbirth.

Urine collects in the bladder, passes through the urethra, and leaves the body at the urethral opening.

Researchers are not sure if a person's erotic G-spot is an actual structure or a sensitive area in the vagina. You can try to find the G-spot by inserting a finger (palm up) a few inches into your vagina. Then, curl your finger in a “come here” motion to see if that stimulates the tissue there.

Lee M, Dalpiaz A, Schwamb R, Miao Y, Waltzer W, Khan A. Clinical pathology of Bartholin’s glands: A review of the literature . Curr Urol . 2015;8(1):22-25. doi:10.1159/000365683

Rodriguez F, Camacho A, Bordes S, Gardner B, Levin R, Tubbs R. Female ejaculation: An update on anatomy, history, and controversies. Clinical Anatomy . 2020;34(1):103-107. doi:10.1002/ca.23654

Giovannetti O, Tomalty D, Gilmore S, et al. The contribution of the cervix to sexual response: an online survey study .  The Journal of Sexual Medicine . 2023;20(1):49-56. doi:10.1093/jsxmed/qdac010

Library of Congress Biology and Human Anatomy. What is the strongest muscle in the body ?

Mishori R, Ferdowsian H, Naimer K, Volpellier M, McHale T. The little tissue that couldn’t – dispelling myths about the Hymen’s role in determining sexual history and assault. Reprod Health . 2019;16(1). doi:10.1186/s12978-019-0731-8

Johns Hopkins Medicine. Anatomy of the breasts .

Kothari C, Diorio C, Durocher F. The importance of breast adipose tissue in breast cancer . Int J Mol Sci . 2020;21(16):5760. doi:10.3390/ijms21165760

Cappelletti M, Wallen K. Increasing women's sexual desire: The comparative effectiveness of estrogens and androgens .  Horm Behav . 2016;78:178-193. doi:10.1016/j.yhbeh.2015.11.003

National Library of Medicine. Anatomy, Abdomen and Pelvis: Female External Genitalia .

Vieira-Baptista P, Lima-Silva J, Preti M, Xavier J, Vendeira P, Stockdale CK. G-spot: Fact or Fiction?: A Systematic Review .  Sex Med . 2021;9(5):100435. doi:10.1016/j.esxm.2021.100435

Boston University School of Medicine. Female genital anatomy .

By Brandi Jones, MSN-ED RN-BC Jones is a registered nurse and freelance health writer with more than two decades of healthcare experience.

6.6 Use of Codes for Surveillance, Data Analysis and Presentation

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The following information is intended primarily for the staff of the central registry. To record ICD-10 codes, the most specific code format (i.e. Q##.#) is used. For example, frontal encephalocele is coded as Q01.0. The three-character format or group code (i.e. Q##) is commonly used only for data analysis and presentation purposes, to group and report all types of any condition. For example, when analysing and reporting all types of (total) encephalocele, the three-character format (Q01) can be used. Diagnoses coded as possible would still be excluded.

Along with the ICD-10 codes, a list with exclusions of several anomalies is provided in the ICD-10 classification system. The term “exclusion” does not necessarily mean that the case is excluded from the registry. Rather, it means that the particular anomaly is not coded using the same code or codes. For example, because “spina bifida occulta” is considered a different anomaly from the other types of spina bifida and has a specific code (Q76.0), the Q05.# ICD-10 codes are not used. Another example is cleft palate with cleft lip. If a fetus or neonate has both a cleft palate and cleft lip, the anomaly is not coded with a cleft palate code (Q35.1–Q35.9), but instead with a code listed under cleft palate with cleft lip (Q37.0–Q37.9).

It is important to keep in mind that while, for surveillance purposes, all major anomalies affecting a fetus or neonate can be coded, for data analysis and presentation, the criteria to include or exclude certain anomalies can determine which codes are used. For example, although a case might have both anencephaly (Q00.0) and lumbar spina bifida without hydrocephalus (Q05.7), for reporting purposes, the case might be analysed only with other cases of anencephaly. In addition, if an anomaly is secondary to another anomaly, such as talipes equinovarus with spina bifida, the case would be included in analyses of spina bifida (Q05.#) but not in analyses of talipes equinovarus (Q66.0 or Q66.8). However, when both anencephaly and spina bifida are present and are contiguous, this is the condition called craniorachischisis for which there is a unique ICD-10 code for that (Q00.1); therefore, anencephaly and spina bifida are not coded separately.

Examples of the assignment of codes based on clinical description are presented next.

The following diagnosis and clinical description are provided for a neonate: “spina bifida with LS meningocele and massive hydrocephalus”

In this case, “LS” is used to abbreviate “lumbosacral”. Although the description might suggest two anomalies (spina bifida and hydrocephalus), hydrocephalus is common among children with spina bifida and it is considered a consequence of spina bifida, the primary major congenital anomaly in this case. There are specific codes for “spina bifida with hydrocephalus” in the ICD-10. The suggested ICD-10 code to assign to this case is Q05.2 (lumbosacral spina bifida with hydrocephalus). This case would not be included in analyses of hydrocephalus as a primary anomaly.

The following diagnosis and clinical description are provided for a neonate: “cleft lip and palate”

Because it is not specified whether the soft palate, hard palate or both are affected and no information is provided regarding the laterality (sidedness) of the cleft lip, the suggested ICD-10 code is Q37.9 (unspecified cleft palate with unilateral cleft lip).

Note: for cleft palate, it is uncommon to have the detailed description available (whether the soft or hard palate is affected), unless the description is provided as a result of a surgical repair.

The following diagnosis and clinical description are provided on a medical record: “cleft lip NOS; spina bifida NOS; ear tags”

The abbreviation “NOS” means “not otherwise specified”. The suggested ICD-10 code for cleft lip NOS is Q36.9 (cleft lip NOS) and for spina bifida NOS is Q05.9 (spina bifida, unspecified). Ear tags are considered minor anomalies; therefore, coding them is optional. If coded, the suggested ICD-10 code for ear tags is Q17.0 (preauricular appendage or tag). Although “NOS” is a valid code in the ICD-10, it is used only when there is no possibility of obtaining a better description for a specific congenital anomaly.

The following diagnosis and clinical description are provided for a neonate: “amelia upper and lower limbs”

There are two ICD-10 codes to be assigned. One is for amelia of upper limbs: Q71.0 (congenital complete absence of the upper limb(s)); the other is for amelia of lower limbs: Q72.0 (congenital complete absence of lower limb(s)). However, for reporting and analytical purposes, it is suggested to count them only once, using the ICD-10 code Q71.0.

The following diagnosis and clinical description are provided as part of an autopsy report: “anencephaly infant with gross abnormalities; bilateral cleft lip; cleft palate”

The suggested ICD-10 code for anencephaly is Q00.0 (anencephaly). The “gross abnormalities” description is vague, and coding is optional. If coded, the suggested ICD-10 code is Q89.9 (congenital malformation, unspecified). Although the description may suggest two anomalies (cleft lip and cleft palate), there is a specific ICD-10 code to assign to cleft palate with bilateral cleft lip. Because the type of cleft palate is not specified, the suggested ICD-10 code is Q37.8 (unspecified cleft palate with bilateral cleft lip).

Note: avoid using the Q89.9 ICD-10 code if possible, because it does not provide any specificity and it has very minimal value in congenital anomalies surveillance.

The following diagnosis and clinical description are provided for a neonate: “myelomeningocele, T3–T4 open”

Since it is not mentioned or specified whether hydrocephalus is present or not, one can assume that the defect is “spina bifida without hydrocephalus” and code as Q05.6 (thoracic spina bifida without hydrocephalus). However, it is also possible to use the ICD-10 code Q05.9 (spina bifida, unspecified) but by using this code the specificity for lesion level would not be captured. It is recommended that the birth defect surveillance programme include information in its protocol on how to code spina bifida when hydrocephalus is not mentioned or described in medical records.

The ICD-10 ( 12 ) and references ( 29 , 41–43 ) provide more information on coding and classification of congenital anomalies.

Table of Contents

• 6. Coding and Diagnosis
• 6.1 Coding of Congenital Anomalies
• 6.2 International Classification of Diseases
• 6.3 Personnel Responsible for Diagnosing and Coding
• 6.4 Effect of the Certainty of Diagnosis on Coding
• 6.5 Coding Multiple Congenital Anomalies
• › 6.6 Use of Codes for Surveillance, Data Analysis and Presentation

Learn how to navigate this website.

• International Clearinghouse for Birth Defects Surveillance and Research (ICBDSR)
• World Health Organization (WHO)

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