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Your baby in the birth canal

During labor and delivery, your baby must pass through your pelvic bones to reach the vaginal opening. The goal is to find the easiest way out. Certain body positions give the baby a smaller shape, which makes it easier for your baby to get through this tight passage.

The best position for the baby to pass through the pelvis is with the head down and the body facing toward the mother's back. This position is called occiput anterior.

Information

Certain terms are used to describe your baby's position and movement through the birth canal.

FETAL STATION

Fetal station refers to where the presenting part is in your pelvis.

• The presenting part. The presenting part is the part of the baby that leads the way through the birth canal. Most often, it is the baby's head, but it can be a shoulder, the buttocks, or the feet.
• Ischial spines. These are bone points on the mother's pelvis. Normally the ischial spines are the narrowest part of the pelvis.
• 0 station. This is when the baby's head is even with the ischial spines. The baby is said to be "engaged" when the largest part of the head has entered the pelvis.
• If the presenting part lies above the ischial spines, the station is reported as a negative number from -1 to -5.

In first-time moms, the baby's head may engage by 36 weeks into the pregnancy. However, engagement may happen later in the pregnancy, or even during labor.

This refers to how the baby's spine lines up with the mother's spine. Your baby's spine is between their head and tailbone.

Your baby will most often settle into a position in the pelvis before labor begins.

• If your baby's spine runs in the same direction (parallel) as your spine, the baby is said to be in a longitudinal lie. Nearly all babies are in a longitudinal lie.
• If the baby is sideways (at a 90-degree angle to your spine), the baby is said to be in a transverse lie.

FETAL ATTITUDE

The fetal attitude describes the position of the parts of your baby's body.

The normal fetal attitude is commonly called the fetal position.

• The head is tucked down to the chest.
• The arms and legs are drawn in towards the center of the chest.

Abnormal fetal attitudes include a head that is tilted back, so the brow or the face presents first. Other body parts may be positioned behind the back. When this happens, the presenting part will be larger as it passes through the pelvis. This makes delivery more difficult.

DELIVERY PRESENTATION

Delivery presentation describes the way the baby is positioned to come down the birth canal for delivery.

The best position for your baby inside your uterus at the time of delivery is head down. This is called cephalic presentation.

• This position makes it easier and safer for your baby to pass through the birth canal. Cephalic presentation occurs in about 97% of deliveries.
• There are different types of cephalic presentation, which depend on the position of the baby's limbs and head (fetal attitude).

If your baby is in any position other than head down, your doctor may recommend a cesarean delivery.

Breech presentation is when the baby's bottom is down. Breech presentation occurs about 3% of the time. There are a few types of breech:

• A complete breech is when the buttocks present first and both the hips and knees are flexed.
• A frank breech is when the hips are flexed so the legs are straight and completely drawn up toward the chest.
• Other breech positions occur when either the feet or knees present first.

The shoulder, arm, or trunk may present first if the fetus is in a transverse lie. This type of presentation occurs less than 1% of the time. Transverse lie is more common when you deliver before your due date, or have twins or triplets.

CARDINAL MOVEMENTS OF LABOR

As your baby passes through the birth canal, the baby's head will change positions. These changes are needed for your baby to fit and move through your pelvis. These movements of your baby's head are called cardinal movements of labor.

• This is when the widest part of your baby's head has entered the pelvis.
• Engagement tells your health care provider that your pelvis is large enough to allow the baby's head to move down (descend).
• This is when your baby's head moves down (descends) further through your pelvis.
• Most often, descent occurs during labor, either as the cervix dilates or after you begin pushing.
• During descent, the baby's head is flexed down so that the chin touches the chest.
• With the chin tucked, it is easier for the baby's head to pass through the pelvis.

Internal Rotation

• As your baby's head descends further, the head will most often rotate so the back of the head is just below your pubic bone. This helps the head fit the shape of your pelvis.
• Usually, the baby will be face down toward your spine.
• Sometimes, the baby will rotate so it faces up toward the pubic bone.
• As your baby's head rotates, extends, or flexes during labor, the body will stay in position with one shoulder down toward your spine and one shoulder up toward your belly.
• As your baby reaches the opening of the vagina, usually the back of the head is in contact with your pubic bone.
• At this point, the birth canal curves upward, and the baby's head must extend back. It rotates under and around the pubic bone.

External Rotation

• As the baby's head is delivered, it will rotate a quarter turn to be in line with the body.
• After the head is delivered, the top shoulder is delivered under the pubic bone.
• After the shoulder, the rest of the body is usually delivered without a problem.

Alternative Names

Shoulder presentation; Malpresentations; Breech birth; Cephalic presentation; Fetal lie; Fetal attitude; Fetal descent; Fetal station; Cardinal movements; Labor-birth canal; Delivery-birth canal

Barth WH. Malpresentations and malposition. In: Landon MB, Galan HL, Jauniaux ERM, et al, eds. Gabbe's Obstetrics: Normal and Problem Pregnancies . 8th ed. Philadelphia, PA: Elsevier; 2021:chap 17.

Kilpatrick SJ, Garrison E, Fairbrother E. Normal labor and delivery. In: Landon MB, Galan HL, Jauniaux ERM, et al, eds. Gabbe's Obstetrics: Normal and Problem Pregnancies . 8th ed. Philadelphia, PA: Elsevier; 2021:chap 11.

Review Date 11/10/2022

Updated by: John D. Jacobson, MD, Department of Obstetrics and Gynecology, Loma Linda University School of Medicine, Loma Linda, CA. Also reviewed by David C. Dugdale, MD, Medical Director, Brenda Conaway, Editorial Director, and the A.D.A.M. Editorial team.

Related MedlinePlus Health Topics

• Childbirth Problems

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• Pregnancy week by week
• Fetal presentation before birth

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

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

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

Head down, face down

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

Head down, face up

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

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

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

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].

Breech presentation.

Caron J. Gray ; Meaghan M. Shanahan .

Affiliations

Last Update: November 6, 2022 .

• Continuing Education Activity

Breech presentation refers to the fetus in the longitudinal lie with the buttocks or lower extremity entering the pelvis first. The three types of breech presentation include frank breech, complete breech, and incomplete breech. In a frank breech, the fetus has flexion of both hips, and the legs are straight with the feet near the fetal face, in a pike position. This activity reviews the cause and pathophysiology of breech presentation and highlights the role of the interprofessional team in its management.

• Describe the pathophysiology of breech presentation.
• Review the physical exam of a patient with a breech presentation.
• Summarize the treatment options for breech presentation.
• Explain the importance of improving care coordination among interprofessional team members to improve outcomes for patients affected by breech presentation.
• Introduction

Breech presentation refers to the fetus in the longitudinal lie with the buttocks or lower extremity entering the pelvis first. The three types of breech presentation include frank breech, complete breech, and incomplete breech. In a frank breech, the fetus has flexion of both hips, and the legs are straight with the feet near the fetal face, in a pike position. The complete breech has the fetus sitting with flexion of both hips and both legs in a tuck position. Finally, the incomplete breech can have any combination of one or both hips extended, also known as footling (one leg extended) breech, or double footling breech (both legs extended). [1] [2] [3]

Clinical conditions associated with breech presentation include those that may increase or decrease fetal motility, or affect the vertical polarity of the uterine cavity. Prematurity, multiple gestations, aneuploidies, congenital anomalies, Mullerian anomalies, uterine leiomyoma, and placental polarity as in placenta previa are most commonly associated with a breech presentation.  Also, a previous history of breech presentation at term increases the risk of repeat breech presentation at term in subsequent pregnancies. [4] [5] These are discussed in more detail in the pathophysiology section.

• Epidemiology

Breech presentation occurs in 3% to 4% of all term pregnancies. A higher percentage of breech presentations occurs with less advanced gestational age. At 32 weeks, 7% of fetuses are breech, and 28 weeks or less, 25% are breech.

Specifically, following one breech delivery, the recurrence rate for the second pregnancy was nearly 10%, and for a subsequent third pregnancy, it was 27%. Prior cesarean delivery has also been described by some to increase the incidence of breech presentation two-fold.

• Pathophysiology

As mentioned previously, the most common clinical conditions or disease processes that result in the breech presentation are those that affect fetal motility or the vertical polarity of the uterine cavity. [6] [7]

Conditions that change the vertical polarity or the uterine cavity, or affect the ease or ability of the fetus to turn into the vertex presentation in the third trimester include:

• Mullerian anomalies: Septate uterus, bicornuate uterus, and didelphys uterus 
• Placentation: Placenta previa as the placenta is occupying the inferior portion of the uterine cavity. Therefore, the presenting part cannot engage
• Uterine leiomyoma: Mainly larger myomas located in the lower uterine segment, often intramural or submucosal, that prevent engagement of the presenting part.
• Prematurity
• Aneuploidies and fetal neuromuscular disorders commonly cause hypotonia of the fetus, inability to move effectively
• Congenital anomalies:  Fetal sacrococcygeal teratoma, fetal thyroid goiter
• Polyhydramnios: Fetus is often in unstable lie, unable to engage
• Oligohydramnios: Fetus is unable to turn to vertex due to lack of fluid
• Laxity of the maternal abdominal wall: Uterus falls forward, the fetus is unable to engage in the pelvis.

The risk of cord prolapse varies depending on the type of breech. Incomplete or footling breech carries the highest risk of cord prolapse at 15% to 18%, while complete breech is lower at 4% to 6%, and frank breech is uncommon at 0.5%.

• History and Physical

During the physical exam, using the Leopold maneuvers, palpation of a hard, round, mobile structure at the fundus and the inability to palpate a presenting part in the lower abdomen superior to the pubic bone or the engaged breech in the same area, should raise suspicion of a breech presentation.

During a cervical exam, findings may include the lack of a palpable presenting part, palpation of a lower extremity, usually a foot, or for the engaged breech, palpation of the soft tissue of the fetal buttocks may be noted. If the patient has been laboring, caution is warranted as the soft tissue of the fetal buttocks may be interpreted as caput of the fetal vertex.

Any of these findings should raise suspicion and ultrasound should be performed.

Diagnosis of a breech presentation can be accomplished through abdominal exam using the Leopold maneuvers in combination with the cervical exam. Ultrasound should confirm the diagnosis.

On ultrasound, the fetal lie and presenting part should be visualized and documented. If breech presentation is diagnosed, specific information including the specific type of breech, the degree of flexion of the fetal head, estimated fetal weight, amniotic fluid volume, placental location, and fetal anatomy review (if not already done previously) should be documented.

• Treatment / Management

Expertise in the delivery of the vaginal breech baby is becoming less common due to fewer vaginal breech deliveries being offered throughout the United States and in most industrialized countries. The Term Breech Trial (TBT), a well-designed, multicenter, international, randomized controlled trial published in 2000 compared planned vaginal delivery to planned cesarean delivery for the term breech infant. The investigators reported that delivery by planned cesarean resulted in significantly lower perinatal mortality, neonatal mortality, and serious neonatal morbidity. Also, there was no significant difference in maternal morbidity or mortality between the two groups. Since that time, the rate of term breech infants delivered by planned cesarean has increased dramatically. Follow-up studies to the TBT have been published looking at maternal morbidity and outcomes of the children at two years. Although these reports did not show any significant difference in the risk of death and neurodevelopmental, these studies were felt to be underpowered. [8] [9] [10] [11]

Since the TBT, many authors since have argued that there are still some specific situations that vaginal breech delivery is a potential, safe alternative to planned cesarean. Many smaller retrospective studies have reported no difference in neonatal morbidity or mortality using these specific criteria.

The initial criteria used in these reports were similar: gestational age greater than 37 weeks, frank or complete breech presentation, no fetal anomalies on ultrasound examination, adequate maternal pelvis, and estimated fetal weight between 2500 g and 4000 g. In addition, the protocol presented by one report required documentation of fetal head flexion and adequate amniotic fluid volume, defined as a 3-cm vertical pocket. Oxytocin induction or augmentation was not offered, and strict criteria were established for normal labor progress. CT pelvimetry did determine an adequate maternal pelvis.

Despite debate on both sides, the current recommendation for the breech presentation at term includes offering external cephalic version (ECV) to those patients that meet criteria, and for those whom are not candidates or decline external cephalic version, a planned cesarean section for delivery sometime after 39 weeks.

Regarding the premature breech, gestational age will determine the mode of delivery. Before 26 weeks, there is a lack of quality clinical evidence to guide mode of delivery. One large retrospective cohort study recently concluded that from 28 to 31 6/7 weeks, there is a significant decrease in perinatal morbidity and mortality in a planned cesarean delivery versus intended vaginal delivery, while there is no difference in perinatal morbidity and mortality in gestational age 32 to 36 weeks. Of note, due to lack of recruitment, no prospective clinical trials are examining this issue.

• Differential Diagnosis
• Face and brow presentation
• Fetal anomalies
• Fetal death
• Grand multiparity
• Multiple pregnancies
• Oligohydramnios
• Pelvis Anatomy
• Preterm labor
• Primigravida
• Uterine anomalies
• Pearls and Other Issues

In light of the decrease in planned vaginal breech deliveries, thus the decrease in expertise in managing this clinical scenario, it is prudent that policies requiring simulation and instruction in the delivery technique for vaginal breech birth are established to care for the emergency breech vaginal delivery.

• Enhancing Healthcare Team Outcomes

A breech delivery is usually managed by an obstetrician, labor and delivery nurse, anesthesiologist and a neonatologist. The ultimate decison rests on the obstetrician. To prevent complications, today cesarean sections are performed and experienced with vaginal deliveries of breech presentation is limited. For healthcare workers including the midwife who has no experience with a breech delivery, it is vital to communicate with an obstetrician, otherwise one risks litigation if complications arise during delivery. [12] [13] [14]

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Disclosure: Caron Gray declares no relevant financial relationships with ineligible companies.

Disclosure: Meaghan Shanahan 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 Gray CJ, Shanahan MM. Breech Presentation. [Updated 2022 Nov 6]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-.

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• [What effect does leg position in breech presentation have on mode of delivery and early neonatal morbidity?]. [Z Geburtshilfe Neonatol. 1997] [What effect does leg position in breech presentation have on mode of delivery and early neonatal morbidity?]. Krause M, Fischer T, Feige A. Z Geburtshilfe Neonatol. 1997 Jul-Aug; 201(4):128-35.
• The effect of intra-uterine breech position on postnatal motor functions of the lower limbs. [Early Hum Dev. 1993] The effect of intra-uterine breech position on postnatal motor functions of the lower limbs. Sival DA, Prechtl HF, Sonder GH, Touwen BC. Early Hum Dev. 1993 Mar; 32(2-3):161-76.
• The influence of the fetal leg position on the outcome in vaginally intended deliveries out of breech presentation at term - A FRABAT prospective cohort study. [PLoS One. 2019] The influence of the fetal leg position on the outcome in vaginally intended deliveries out of breech presentation at term - A FRABAT prospective cohort study. Jennewein L, Allert R, Möllmann CJ, Paul B, Kielland-Kaisen U, Raimann FJ, Brüggmann D, Louwen F. PLoS One. 2019; 14(12):e0225546. Epub 2019 Dec 2.
• Review Breech vaginal delivery at or near term. [Semin Perinatol. 2003] Review Breech vaginal delivery at or near term. Tunde-Byass MO, Hannah ME. Semin Perinatol. 2003 Feb; 27(1):34-45.
• Review [Breech Presentation: CNGOF Guidelines for Clinical Practice - Epidemiology, Risk Factors and Complications]. [Gynecol Obstet Fertil Senol. 2...] Review [Breech Presentation: CNGOF Guidelines for Clinical Practice - Epidemiology, Risk Factors and Complications]. Mattuizzi A. Gynecol Obstet Fertil Senol. 2020 Jan; 48(1):70-80. Epub 2019 Nov 1.

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Presentation and position of baby through pregnancy and at birth

9-minute read

If you are concerned about your baby’s movements, contact your doctor or midwife for advice immediately.

• If you baby is in a breech presentation, your doctor may recommend trying a technique called an external cephalic version to try and move your baby while they are still in the uterus for an easier birth.

What does presentation and position mean?

Presentation refers to the part of your baby’s body that is facing downwards in the direction of the birth canal.

Position refers to where your baby’s occiput (the bottom part of the back of their head) is in relation to your body.

If your baby is in a breech presentation , then position refers to where your baby’s sacrum (lower back) is in relation to your body.

People — including medical professionals — sometimes use these terms incorrectly. Sometimes when speaking about babies in breech presentation, the word ‘position’ will be used to refer to their presentation. For example, you may read information or hear people say ‘breech position’ instead of ‘breech presentation’.

What are the different types of presentation my baby could be in during pregnancy and birth?

Most babies present headfirst, also known as cephalic presentation. Most babies that are headfirst will be vertex presentation. This means that the crown of their head sits at the opening of your birth canal.

In rare cases, your baby can be headfirst but in face or brow presentation, which may not be suitable for vaginal birth.

If your baby is in a breech presentation, their feet or bottom will be closest to your birth canal. The 3 most common types of breech presentation are:

• frank or extended breech — where your baby’s legs are straight up in front of their body, with their feet up near their face
• complete or flexed breech — where your baby is in a sitting position with their legs crossed in front of their body and their feet near their bottom
• footling breech — where one or both of your baby’s feet are hanging below their bottom, so the foot or feet are coming first

Read more on breech presentation .

What are the different positions my baby could be in during pregnancy and birth?

If your baby is headfirst, the 3 main types of presentation are:

• anterior – when the back of your baby’s head is at the front of your belly
• lateral – when the back of your baby’s head is facing your side
• posterior – when the back of your baby’s head is towards your back

How will I know what presentation and position my baby is in?

Your doctor or midwife can usually work out your baby’s presentation by feeling your abdomen. They may also double check it with a portable ultrasound. Your baby’s presentation is usually checked around 36 weeks .

Your doctor or midwife will also confirm your baby’s head position in labour by examining your belly and using an ultrasound , and they may also do a vaginal examination . During the vaginal examination they are feeling for certain ridges on your baby’s head called sutures and fontanelles that help them work out which way your baby is positioned.

What is the ideal presentation and position for baby to be in for a vaginal birth?

For a vaginal birth, your baby will ideally be headfirst with the back of their head at the front of your belly, also known as being in the anterior position. This position is best for labour and birth since it means that the smallest part of your baby’s head goes down the birth canal first.

When does a baby usually get in the ideal presentation and position for birth?

Your baby will usually be in a headfirst position by 37 weeks of pregnancy. Around 3 in every 100 babies will be in breech presentation after 37 weeks.

Your baby’s position can change with your contractions during labour as they move down the birth canal, so their exact position can change during labour.

What are my options if baby isn't in the ideal presentation or position for a vaginal birth?

If your baby is in a breech presentation, your doctor may recommend a technique called an external cephalic version (ECV) to try and move your baby while they are still in the uterus . An ECV involves your doctor using their hands to apply pressure on your belly and help turn your baby to a headfirst position. It has a 1 in 2 chance of success and is a safe option in most pregnancies.

There is no evidence to show that alternative therapies, such as exercises, acupuncture or chiropractic treatments, help your baby change from a breech presentation to headfirst.

If your baby remains breech, your doctor may discuss having a breech vaginal birth. Not all doctors and hospitals offer this option. They may also suggest you birth your baby with a planned caesarean section .

If your baby’s presentation is headfirst but the position of your baby’s head is not ideal for labour, it can lead to a longer labour, and potential complications . The position of your baby’s head will often change as your labour progresses. If it doesn’t, sometimes you can still give birth without assistance, or you may need your doctor to help turn your baby’s head or help your birth with a vacuum or forceps .

Any procedure or decision for a type of birth will only go ahead with your consent . You will be able to discuss all the options with your doctor, and based on your preferences for yourself and your baby’s safety, make a decision together .

Resources and support

The Royal Australian and New Zealand College of Obstetrics and Gynaecology has a factsheet about the options available to you if your baby is in a breech presentation at the end of your pregnancy .

Mercy Perinatal has information on external cephalic version (ECV) safety and benefits if your baby is in a breech presentation at the end of your pregnancy.

The Women’s Hospital has information about the different presentations and positions your baby could be in, and how it can affect your birthing experience.

Speak to a maternal child health nurse

Call Pregnancy, Birth and Baby to speak to a maternal child health nurse on 1800 882 436 or video call . Available 7am to midnight (AET), 7 days a week.

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Last reviewed: October 2023

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Breech presentation and turning the baby

In preparation for a safe birth, your health team will need to turn your baby if it is in a bottom first ‘breech’ position.

Read more on WA Health website

Breech Presentation at the End of your Pregnancy

Breech presentation occurs when your baby is lying bottom first or feet first in the uterus (womb) rather than the usual head first position. In early pregnancy, a breech position is very common.

Read more on RANZCOG - Royal Australian and New Zealand College of Obstetricians and Gynaecologists website

External Cephalic Version for Breech Presentation - Pregnancy and the first five years

This information brochure provides information about an External Cephalic Version (ECV) for breech presentation

Read more on NSW Health website

When a baby is positioned bottom-down late in pregnancy, this is called the breech position. Find out about 3 main types and safe birthing options.

Read more on Pregnancy, Birth & Baby website

Malpresentation is when your baby is in an unusual position as the birth approaches. Sometimes it’s possible to move the baby, but a caesarean maybe safer.

Labour complications

Even if you’re healthy and well prepared for childbirth, there’s always a chance of unexpected problems. Learn more about labour complications.

ECV is a procedure to try to move your baby from a breech position to a head-down position. This is performed by a trained doctor.

Having a baby

The articles in this section relate to having a baby – what to consider before becoming pregnant, pregnancy and birth, and after your baby is born.

Anatomy of pregnancy and birth - pelvis

Your pelvis helps to carry your growing baby and is tailored for vaginal births. Learn more about the structure and function of the female pelvis.

Planned or elective caesarean

There are important things to consider if you are having a planned or elective caesarean such as what happens during and after the procedure.

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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.

Was this article helpful?

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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]

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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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Chapter 27:  Compound Presentations

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Prolapse of hand and arm or foot and leg.

• MANAGEMENT OF COMPOUND PRESENTATIONS
• Full Chapter
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A presentation is compound when there is prolapse of one or more of the limbs along with the head or the breech, both entering the pelvis at the same time. Footling breech or shoulder presentations are not included in this group. Associated prolapse of the umbilical cord occurs in 15 to 20 percent of cases.

Easily detectable compound presentations occur probably once in 500 to 1000 confinements. It is impossible to establish the exact incidence because:

Spontaneous correction occurs frequently, and examination late in labor cannot provide the diagnosis

Minor degrees of prolapse are detected only by early and careful vaginal examination

Classification of Compound Presentation

Upper limb (arm–hand), one or both

Lower limb (leg–foot), one or both

Arm and leg together

Breech presentation with prolapse of the hand or arm

By far the most frequent combination is that of the head with the hand ( Fig. 27-1 ) or arm. In contrast, the head–foot and breech–arm groups are uncommon, about equally so. Prolapse of both hand and foot alongside the head is rare. All combinations may be complicated by prolapse of the umbilical cord, which then becomes the major problem.

FIGURE 27-1.

Compound presentation: head and hand.

The etiology of compound presentation includes all conditions that prevent complete filling and occlusion of the pelvic inlet by the presenting part. The most common causal factor is prematurity. Others include high presenting part with ruptured membranes, polyhydramnios, multiparity, a contracted pelvis, pelvic masses, and twins. It is also more common with inductions of labor involving floating presenting parts. Another predisposing factor is external cephalic version. During the process of external version, a fetal limb (commonly the hand–arm, but occasionally the foot) can become “trapped” before the fetal head and thus become the presenting part when labor ensues.

Diagnosis is made by vaginal examination, and in many cases, the condition is not noted until labor is well advanced and the cervix is fully dilated.

The condition is suspected when:

There is delay of progress in the active phase of labor

Engagement fails to occur

The fetal head remains high and deviated from the midline during labor, especially after the membranes rupture

In the absence of complications and with conservative management, the results should be no worse than with other presentations.

Mechanism of Labor

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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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Obstetric and Newborn Care I

10.02 key terms related to fetal positions.

a. “Lie” of an Infant.

Lie refers to the position of the spinal column of the fetus in relation to the spinal column of the mother. There are two types of lie, longitudinal and transverse. Longitudinal indicates that the baby is lying lengthwise in the uterus, with its head or buttocks down. Transverse indicates that the baby is lying crosswise in the uterus.

b. Presentation/Presenting Part.

Presentation refers to that part of the fetus that is coming through (or attempting to come through) the pelvis first.

(1) Types of presentations (see figure 10-1). The vertex or cephalic (head), breech, and shoulder are the three types of presentations. In vertex or cephalic, the head comes down first. In breech, the feet or buttocks comes down first, and last–in shoulder, the arm or shoulder comes down first. This is usually referred to as a transverse lie.

(2) Percentages of presentations.

(a) Head first is the most common-96 percent.

(b) Breech is the next most common-3.5 percent.

(c) Shoulder or arm is the least common-5 percent.

(3) Specific presentation may be evaluated by several ways.

(a) Abdominal palpation-this is not always accurate.

(b) Vaginal exam–this may give a good indication but not infallible.

(c) Ultrasound–this confirms assumptions made by previous methods.

(d) X-ray–this confirms the presentation, but is used only as a last resort due to possible harm to the fetus as a result of exposure to radiation.

c. Attitude.

This is the degree of flexion of the fetus body parts (body, head, and extremities) to each other. Flexion is resistance to the descent of the fetus down the birth canal, which causes the head to flex or bend so that the chin approaches the chest.

(1) Types of attitude (see figure 10-2).

(a) Complete flexion. This is normal attitude in cephalic presentation. With cephalic, there is complete flexion at the head when the fetus “chin is on his chest.” This allows the smallest cephalic diameter to enter the pelvis, which gives the fewest mechanical problems with descent and delivery.

(b) Moderate flexion or military attitude. In cephalic presentation, the fetus head is only partially flexed or not flexed. It gives the appearance of a military person at attention. A larger diameter of the head would be coming through the passageway.

(c) Poor flexion or marked extension. In reference to the fetus head, it is extended or bent backwards. This would be called a brow presentation. It is difficult to deliver because the widest diameter of the head enters the pelvis first. This type of cephalic presentation may require a C/Section if the attitude cannot be changed.

(d) Hyperextended. In reference to the cephalic position, the fetus head is extended all the way back. This allows a face or chin to present first in the pelvis. If there is adequate room in the pelvis, the fetus may be delivered vaginally.

(2) Areas to look at for flexion.

(a) Head-discussed in previous paragraph, 10-2c(1).

(b) Thighs-flexed on the abdomen.

(c) Knees-flexed at the knee joints.

(d) Arches of the feet-rested on the anterior surface of the legs.

(e) Arms-crossed over the thorax.

(3) Attitude of general flexion. This is when all of the above areas are flexed appropriately as described.

d. Station.

This refers to the depth that the presenting part has descended into the pelvis in relation to the ischial spines of the mother’s pelvis. Measurement of the station is as follows:

(1) The degree of advancement of the presenting part through the pelvis is measured in centimeters.

(2) The ischial spines is the dividing line between plus and minus stations.

(3) Above the ischial spines is referred to as -1 to -5, the numbers going higher as the presenting part gets higher in the pelvis (see figure10-3).

(4) The ischial spines is zero (0) station.

(5) Below the ischial spines is referred to +1 to +5, indicating the lower the presenting part advances.

e. Engagement.

This refers to the entrance of the presenting part of the fetus into the true pelvis or the largest diameter of the presenting part into the true pelvis. In relation to the head, the fetus is said to be engaged when it reaches the midpelvis or at a zero (0) station. Once the fetus is engaged, it (fetus) does not go back up. Prior to engagement occurring, the fetus is said to be “floating” or ballottable.

f. Position.

This is the relationship between a predetermined point of reference or direction on the presenting part of the fetus to the pelvis of the mother.

(1) The maternal pelvis is divided into quadrants.

(a) Right and left side, viewed as the mother would.

(b) Anterior and posterior. This is a line cutting the pelvis in the middle from side to side. The top half is anterior and the bottom half is posterior.

(c) The quadrants never change, but sometimes it is confusing because the student or physician’s viewpoint changes.

NOTE: Remember that when you are describing the quadrants, view them as the mother would.

(2) Specific points on the fetus.

(a) Cephalic or head presentation.

1 Occiput (O). This refers to the Y sutures on the top of the head.

2 Brow or fronto (F). This refers to the diamond sutures or anterior fontanel on the head.

3 Face or chin presentation (M). This refers to the mentum or chin.

(b) Breech or butt presentation.

1 Sacrum or coccyx (S). This is the point of reference.

2 Breech birth is associated with a higher perinatal mortality.

(c) Shoulder presentation.

1 This would be seen with a transverse lie.

2. Scapula (Sc) or its upper tip, the acromion (A) would be used for the point of reference.

(3) Coding of positions.

(a) Coding simplifies explaining the various positions.

1 The first letter of the code tells which side of the pelvis the fetus reference point is on (R for right, L for left).

2 The second letter tells what reference point on the fetus is being used (Occiput-O, Fronto-F, Mentum-M, Breech-S, Shoulder-Sc or A).

3 The last letter tells which half of the pelvis the reference point is in (anterior-A, posterior-P, transverse or in the middle-T).

(b) Each presenting part has the possibility of six positions. They are normally recognized for each position–using “occiput” as the reference point.

1 Left occiput anterior (LOA).

2 Left occiput posterior (LOP).

3 Left occiput transverse (LOT).

4 Right occiput anterior (ROA).

5. Right occiput posterior (ROP).

6 Right occiput transverse (ROT).

(c) A transverse position does not use a first letter and is not the same as a transverse lie or presentation.

1 Occiput at sacrum (O.S.) or occiput at posterior (O.P.).

2 Occiput at pubis (O.P.) or occiput at anterior (O.A.).

(4) Types of breech presentations (see figure10-4).

(a) Complete or full breech. This involves flexion of the fetus legs. It looks like the fetus is sitting in a tailor fashion. The buttocks and feet appear at the vaginal opening almost simultaneously.

A–Complete. B–Frank. C–Incomplete.

(b) Frank and single breech. The fetus thighs are flexed on his abdomen. His legs are against his trunk and feet are in his face (foot-in-mouth posture). This is the most common and easiest breech presentation to deliver.

(c) Incomplete breech. The fetus feet or knees will appear first. His feet are labeled single or double footing, depending on whether 1 or 2 feet appear first.

(5) Observations about positions (see figure 10-5).

(a) LOA and ROA positions are the most common and permit relatively easy delivery.

(b) LOP and ROP positions usually indicate labor may be longer and harder, and the mother will experience severe backache.

(c) Knowing positions will help you to identify where to look for FHT’s.

1 Breech. This will be upper R or L quad, above the umbilicus.

2 Vertex. This will be lower R or L quad, below the umbilicus.

(d) An occiput in the posterior quadrant means that you will feel lumpy fetal parts, arms and legs (see figure 10-5 A). If delivered in that position, the infant will come out looking up.

(e) An occiput in the anterior quadrant means that you will feel a more smooth back (see figure 10-5 B). If delivered in that position, the infant will come out looking down at the floor.

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Labor and Birth

Labor and Birth Just the facts In this chapter, you’ll learn: types of fetal presentations and positions ways in which labor can be stimulated signs and symptoms of labor stages and cardinal movements of labor nursing responsibilities during labor and birth, including ways to provide comfort and support. A look at labor and birth Labor and birth is physically and emotionally straining for a woman. As the patient’s body undergoes physical changes to help the fetus pass through the cervix, she may also feel discomfort, pain, panic, irritability, and loss of control. To ensure the safest outcome for the mother and child, you must fully understand the stages of labor as well as the factors affecting its length and difficulty. With an understanding of the labor and birth process, you’ll be better able to provide supportive measures that promote relaxation and help increase the patient’s sense of control. Fetal presentation Fetal presentation is the relationship of the fetus to the cervix. It can be assessed through vaginal examination, abdominal inspection and palpation, sonography, or auscultation of fetal heart tones. By knowing the fetal presentation, you can anticipate which part of the fetus will first pass through the cervix during delivery. How long and how hard Fetal presentation can affect the length and difficulty of labor as well as how the fetus is delivered. For example, if the fetus is in a breech presentation (the fetus’s soft buttocks are presenting first), the force exerted against the cervix by uterine contractions is less than it would be if the fetus’s firm head presented first. The decreased force against the cervix decreases the effectiveness of the uterine contractions that help open the cervix and push the fetus through the birth canal. Presenting difficulties Sometimes, the fetus’s presenting part is too large to pass through the mother’s pelvis or the fetus is in a position that’s undeliverable. In such cases, cesarean birth may be necessary. In addition to the usual risks associated with surgery, an abnormal fetal presentation increases the risk of complications for the mother and fetus. Factors determining fetal presentation The primary factors that determine fetal presentation during birth are fetal attitude, lie, and position. Fetal attitude Fetal attitude (degree of flexion) is the relationship of the fetal body parts to one another. It indicates whether the presenting parts of the fetus are in flexion (complete or moderate) or extension (partial or full). What’s in an attitude? Complete flexion Moderate flexion Partial extension Full extension In complete flexion, the head of the fetus is tucked down onto the chest, with the chin touching the sternum. Moderate flexion (aka military position or sinciput), the head of the fetus is slightly flexed but held straighter than in complete flexion. The chin doesn’t touch the chest. In partial extension, the head of the fetus is extended, with the head pushed slightly backward so that the brow becomes the first part of the fetus to pass through the pelvis during birth. In complete extension, the head and neck of the fetus are hyperextended and the occiput touches the fetus’s upper back. The back is usually arched, which increases the degree of hyperextension. This position is commonly called the fetal position. Many fetuses assume this attitude early in labor but convert to complete flexion as labor progresses. This is an uncommon fetal position and a vaginal birth is unlikely. Commonly, this skull diameter is too large to pass through the pelvis. The occiput is the presenting part. The top of the head is the presenting part. The brow or forehead is the presenting part. The mentum (chin) is the presenting part. Fetal lie The relationship of the fetal spine to the maternal spine is referred to as fetal lie. Fetal lie can be described as longitudinal, transverse, or oblique. Fetal position Fetal position is the relationship of the presenting part of the fetus to a specific quadrant of the mother’s pelvis. It’s important to define fetal position because it influences the progression of labor and whether surgical intervention is needed. Spelling it out Fetal position is defined using three letters. The first letter designates whether the presenting part is facing the woman’s right (R) or left (L) side. The second letter or letters refer to the presenting part of the fetus: the occiput (O), mentum (M), sacrum (Sa), or scapula or acromion process (A). The third letter designates whether the presenting part is pointing to the anterior (A), posterior (P), or transverse (T) section of the mother’s pelvis. The most common fetal positions are left occiput anterior (LOA) and right occiput anterior (ROA). (See Fetal position abbreviations , page 298 .) Duration determinant Commonly, the duration of labor and birth is shortest when the fetus is in the LOA or ROA position. When the fetal position is posterior, such as left occiput posterior (LOP), labor tends to be longer and more painful for the woman because the fetal head puts pressure on her sacral nerves. (See Determining fetal position .) Which way do I Lie? Longitudinal Transverse Oblique The fetal spine is parallel to the maternal spine. The fetal spine is at a 90-degree angle to the maternal spine. The fetal spine is at a 45-degree angle to the maternal spine. Approximately 99% of all fetuses are in this position. The presenting part can be either vertex or breech. Occurs in less than 1% of all deliveries and is considered abnormal. The presenting part can be a shoulder, an iliac crest, a hand, or an elbow. Also considered abnormal and is rare. The presenting part can also be a shoulder, an iliac crest, a hand, or an elbow. Fetal position abbreviations Here’s a list of presentations that are used when documenting vertex presentations. Although it is possible to apply the same abbreviation system to breech (sacrum), face (mentum) and shoulder (acromion process) presentation, it is rarely done due to those presentations precipitating a cesarean section delivery. Vertex presentations (occiput) LOA, left occipitoanterior ROA, right occipitoanterior LOP, left occipitoposterior ROP, right occipitoposterior LOT, left occipitotransverse ROT, right occipitotransverse Types of fetal presentation Fetal presentation refers to the part of the fetus that presents into the birth canal first. It’s determined by fetal attitude, lie, and position. Fetal presentation should be determined in the early stages of labor in case an abnormal presentation endangers the mother and the fetus. (See Classifying fetal presentation , pages 300 and 301.) The four main types of fetal presentation are: cephalic breech shoulder compound. Cephalic presentation When the fetus is in cephalic presentation, the head is the first part to contact the cervix and expel from the uterus during delivery. About 95% of all fetuses are in cephalic presentation at birth. The four types of cephalic presentation are vertex, brow, face, and mentum (chin). Determining fetal position Fetal position is determined by the relationship of a specific presenting part (occiput, sacrum, mentum [chin], or sinciput [deflected vertex]) to the four quadrants (anterior, posterior, right, or left) of the maternal pelvis. For example, a fetus whose occiput (O) is the presenting part and who’s located in the right (R) and anterior (A) quadrant of the maternal pelvis is identified as ROA. These illustrations show the possible positions of a fetus in vertex presentation. Vertex In the vertex cephalic presentation, the most common presentation overall, the fetus is in a longitudinal lie with an attitude of complete flexion. The parietal bones (between the two fontanels) are the presenting part of the fetus. This presentation is considered optimal for fetal descent through the pelvis. Classifying fetal presentation Fetal presentation may be broadly classified as cephalic, shoulder, compound, or breech. Almost all births are cephalic presentations. Breech births are the second most common type. Cephalic In the cephalic, or head-down, presentation, the position of the fetus may be further classified by the presenting skull landmark, such as vertex, brow, sinciput, or mentum (chin). Shoulder Although a fetus may adopt one of several shoulder presentations, examination can’t differentiate among them; thus, all transverse lies are considered shoulder presentations. Compound In compound presentation, an extremity prolapses alongside the major presenting part so that two presenting parts appear in the pelvis at the same time. Breech In the breech, or head-up, presentation, the position of the fetus may be further classified as frank, where the hips are flexed and knees remain straight; complete, where the knees and hips are flexed; kneeling, where the knees are flexed and the hips remain extended; and incomplete, where one or both hips remain extended and one or both feet or knees lie below the breech; or footling, where one or both feet extend below the breech. Brow In brow presentation, the fetus’s brow or forehead is the presenting part. The fetus is in a longitudinal lie and exhibits an attitude of partial flexion. Although this isn’t the optimal presentation for a fetus, few suffer serious complications from the delivery. In fact, many brow presentations convert to vertex presentations during descent through the pelvis. Face The face type of cephalic presentation is unfavorable for the mother and the fetus. In this presentation, the fetus is in a longitudinal lie and exhibits an attitude of complete extension. Because the face is the presenting part of the fetal head, severe edema and facial distortion may occur from the pressure of uterine contractions during labor. Faced with potential complications If labor is allowed to progress, careful monitoring of both the fetus and the mother is necessary to reduce the risk of compromise. Labor may be prolonged and ineffective in some instances, and vaginal birth may not be possible because the presenting part has a larger diameter than the pelvic outlet. Attempts to manually convert the face presentation to a more favorable position are rarely successful and are associated with high perinatal mortality and maternal morbidity. Mentum The mentum, or chin, type of cephalic presentation is also unfavorable for the mother and the fetus. In this presentation, the fetus is in a longitudinal lie with an attitude of complete extension. The presenting part of the fetus is the chin, which may lead to severe edema and facial distortion from the pressure of the uterine contractions during labor. The widest diameter of the fetal head is presenting through the pelvis because of the extreme extension of the head. If labor is allowed to progress, careful monitoring of both the fetus and the mother is necessary to reduce the risk of compromise. Labor is usually prolonged and ineffective. Vaginal delivery is usually impossible because the fetus can’t pass through the ischial spines. Breech presentation Although 25% of all fetuses are in breech presentation at week 30 of gestation, most turn spontaneously at 32 to 34 weeks’ gestation. However, breech presentation occurs at term in about 3% of births. Labor is usually prolonged with breech presentation because of ineffective cervical dilation caused by decreased pressure on the cervix and delayed descent of the fetus. It gets complicated In addition to prolonging labor, the breech presentation increases the risk of complications. In the fetus, cord prolapse; anoxia; intracranial hemorrhage caused by rapid molding of the head; neck trauma; and shoulder, arm, hip, and leg dislocations or fractures may occur. Complications that may occur in the mother include perineal tears and cervical lacerations during delivery and infection from premature rupture of the membranes. How will I know? A breech presentation can be identified by abdominal and cervical examination. The signs of breech presentation include: fetal head is felt at the uterine fundus during an abdominal examination fetal heart tones are heard above the umbilicus soft buttocks or feet are palpated during a cervical examination. Once, twice, three types more The three types of breech presentation are complete, frank, and incomplete. Complete breech In a complete breech presentation, the fetus’s buttocks and the feet are the presenting parts. The fetus is in a longitudinal lie and is in complete flexion. The fetus is sitting crossed-legged and both legs are drawn up (hips flexed) with the anterior of the thighs pressed tightly against the abdomen; the lower legs are crossed with the calves pressed against the posterior of the thighs; and the feet are tightly flexed against the outer aspect of the posterior thighs. Although considered an abnormal fetal presentation, complete breech is the least difficult of the breech presentations. Frank breech In a frank breech presentation, the fetus’s buttocks are the presenting part. The fetus is in a longitudinal lie and is in moderate flexion. Both legs are drawn up (hips flexed) with the anterior of the thighs pressed against the body; the knees are fully extended and resting on the upper body with the lower legs stretched upward; the arms may be flexed over or under the legs; and the feet are resting against the head. The attitude is moderate. Incomplete breech In an incomplete breech presentation, also called a footling breech, one or both of the knees or legs are the presenting parts. If one leg is extended, it’s called a single-footling breech (the other leg may be flexed in the normal attitude); if both legs are extended, it’s called a double-footling breech. The fetus is in a longitudinal lie. At least one of the thighs and one of the lower legs are extended with little or no hip flexion. Perhaps expect prolapse A footling breech is the most difficult of the breech deliveries. Cord prolapse is common in a footling breech because of the space created by the extended leg. A cesarean birth may be necessary to reduce the risk of fetal or maternal mortality. Shoulder presentation Although common in multiple pregnancies, the shoulder presentation of the fetus is an abnormal presentation that occurs in less than 1% of deliveries. In this presentation, the shoulder, iliac crest, hand, or elbow is the presenting part. The fetus is in a transverse lie, and the attitude may range from complete flexion to complete extension. Lacking space and support In the multiparous woman, shoulder presentation may be caused by the relaxation of the abdominal walls. If the abdominal walls are relaxed, the unsupported uterus falls forward, causing the fetus to turn horizontally. Other causes of shoulder presentation may include pelvic contraction (the vertical space in the pelvis is smaller than the horizontal space) or placenta previa (the low-lying placenta decreases the vertical space in the uterus). Early identification and intervention are critical when the fetus is in a shoulder presentation. Abdominal and cervical examination and sonography are used to confirm whether the mother’s abdomen has an abnormal or distorted shape. Attempts to turn the fetus may be unsuccessful unless the fetus is small or preterm. A cesarean delivery may be necessary to reduce the risk of fetal or maternal death. Compound presentation In a compound presentation, an extremity presents with another major presenting part, usually the head. In this type of presentation, the extremity prolapses alongside the major presenting part so that they present simultaneously. Engagement Engagement occurs when the presenting part of the fetus passes into the pelvis to the point where, in cephalic presentation, the biparietal diameter of the fetal head is at the level of the midpelvis (or at the level of the ischial spines). Vaginal and cervical examinations are used to assess the degree of engagement before and during labor. A good sign Because the ischial spines are usually the narrowest area of the female pelvis, an engagement indicates that the pelvic inlet is large enough for the fetus to pass through (because the widest part of the fetus has already passed through the narrowest part of the pelvis). Floating away In the primipara, nonengagement of the presenting part at the onset of labor may indicate a complication, such as cephalopelvic disproportion, abnormal presentation or position, or an abnormality of the fetal head. The nonengaged presenting part is described as floating. In the multipara, nonengagement is common at the onset of labor; however, the presenting part quickly becomes engaged as labor progresses. Station Station is the relationship of the presenting part of the fetus to the mother’s ischial spines. If the fetus is at station 0, the fetus is considered to be at the level of the ischial spines. The fetus is considered engaged when it reaches station 0. Grand central stations Fetal station is measured in centimeters. The measurement is called minus when it’s above the level of the ischial spines and plus when it’s below that level. Station measurements range from — 1 to — 3 cm (minus station) and + 1 to + 4 cm (plus station). A crowning achievement When the station is measured at + 4 cm, the presenting part of the fetus is at the perineum—commonly known as crowning. (See Assessing fetal engagement and station , page 306 .) Advice from the experts Assessing fetal engagement and station During a cervical examination, you’ll assess the extent of the fetal presenting part into the pelvis. This is referred to as fetal engagement. After you have determined fetal engagement, palpate the presenting part and grade the fetal station (where the presenting part lies in relation to the ischial spines of the maternal pelvis). If the presenting part isn’t fully engaged into the pelvis, you won’t be able to assess station. Station grades range from —3 (3 cm above the maternal ischial spines) to +4 (4 cm below the maternal ischial spines, causing the perineum to bulge). A zero grade indicates that the presenting part lies level with the ischial spines. A look at labor stimulation For some patients, it’s necessary to stimulate labor. The stimulation of labor may involve induction (artificially starting labor) or augmentation (assisting a labor that started spontaneously). Although induction and augmentation involve the same methods and risks, they’re performed for different reasons. Many high-risk pregnancies must be induced because the safety of the mother or fetus is in jeopardy. Medical problems that justify induction of labor include preeclampsia, eclampsia, severe hypertension, diabetes, Rh sensitization, prolonged rupture of the membranes (over 24 hours), and a postmature fetus (a fetus that’s 42 weeks’ gestation or older). Augmentation of labor may be necessary if the contractions are too weak or infrequent to be effective. Conditions for labor stimulation Before stimulating labor, the fetus must be: in longitudinal lie (the long axis of the fetus is parallel to the long axis of the mother) at least 39 weeks’ gestation or have fetal lung maturity established The ripe type In addition to the above fetal criteria, the mother must have a ripe cervix before labor is induced. A ripe cervix is soft and supple to the touch rather than firm. Softening of the cervix allows for cervical effacement, dilation, and effective coordination of contractions. Using Bishop score, you can determine whether a cervix is ripe enough for induction. (See Bishop score , page 308 .) When it isn’t so great to stimulate Stimulation of labor should be done with caution in women age 35 and older and in those with grand parity or uterine scars. Labor should not be stimulated if, but not limited to: transverse fetal position umbilical cord prolapse active genital herpes infections women who have had previous myomectomy (fibroid removal) from the inside of the uterus stimulation of the uterus increases the risk of such complications as placenta previa, abruptio placentae, uterine rupture, and decreased fetal blood supply caused by the increased intensity or duration of contractions. Methods of labor stimulation If labor is to be induced or augmented, one method or a combination of methods may be used. Methods of labor stimulation include breast stimulation, amniotomy, oxytocin administration, and ripening agent application. Breast stimulation In breast stimulation, the nipples are massaged to induce labor. Stimulation results in the release of oxytocin, which causes contractions that sometimes result in labor. The patient or her partner can help with breast stimulation by: applying a water-soluble lubricant to the nipple area (to prevent irritation) gently rolling the nipple through the patient’s clothing. Too much, too soon? One drawback of breast stimulation is that the amount of oxytocin being released by the woman’s body can’t be controlled. In some cases (rarely), too much oxytocin leads to excessive uterine stimulation (tachysystole or tetanic contractions), which impairs fetal or placental blood flow, causing fetal distress. Bishop score Bishop score is a tool that you can use to assess whether a woman is ready for labor. A score ranging from 0 to 3 is given for each of five factors: cervical dilation, length (effacement), consistency, position, and station. If the woman’s score exceeds 8, the cervix is considered suitable for induction. Factor Score Cervical dilation • Cervix dilated <1 cm 0 • Cervix dilated 1 to 2 cm 1 • Cervix dilated 2 to 4 cm 2 • Cervix dilated >4 cm 3 Cervical length (effacement) • Cervical length >4 cm (0% effaced) 0 • Cervical length 2 to 4 cm (0% to 50% effaced) 1 • Cervical length 1 to 2 cm (50% to 75% effaced) 2 • Cervical length <1 cm (>75% effaced) 3 Cervical consistency • Firm cervical consistency 0 • Average cervical consistency 1 • Soft cervical consistency 2 Cervical position • Posterior cervical position 0 • Middle or anterior cervical position 1 Zero station notation (presenting part level) • Presenting part at ischial spines —3 cm 0 • Presenting part at ischial spines —1 cm 1 • Presenting part at ischial spines +1 cm 2 • Presenting part at ischial spines +2 cm 3 Modifiers Add 1 point to score for: Preeclampsia Each prior vaginal delivery Subtract 1 point from score for: Postdates pregnancy Nulliparity Premature or prolonged rupture of membranes Adapted with permission from Bishop, E. H. (1964). Pelvic scoring for elective induction. Obstetrics and Gynecology, 24, 266-268. Amniotomy Amniotomy (artificial rupturing of the membranes) is performed to augment or induce labor when the membranes haven’t ruptured spontaneously. This procedure allows the fetal head to contact the cervix more directly, thus increasing the efficiency of contractions. Amniotomy is virtually painless for both the mother and the fetus because the membranes don’t have nerve endings. System requirements To perform amniotomy, the fetus must be in the vertex presentation with the cervix dilated to at least 2 cm; additionally, the head should be well applied to the cervix to help prevent umbilical cord prolapse. Nurse need to be aware of the potential for umbilical cord prolapse during an amniotomy if the head is not fully engaged into the pelvis at zero station. Let it flow, let it flow, let it flow During amniotomy, the woman is placed in a dorsal recumbent position. An amniohook (a long, thin instrument similar to a crochet hook) is inserted into the vagina to puncture the membranes. If puncture is properly performed, amniotic fluid gushes out. Advice from the experts Complications of amniotomy Umbilical cord prolapse—a life-threatening complication of amniotomy—is an emergency that requires immediate cesarean birth to prevent fetal death. It occurs when amniotic fluid, gushing from the ruptured sac, sweeps the cord down through the cervix. Prolapse risk is higher if the fetal head isn’t engaged in the pelvis before rupture occurs. Cord prolapse can lead to cord compression as the fetal presenting part presses the cord against the pelvic brim. Immediate action must be taken to relieve the pressure and prevent fetal anoxia and fetal distress. Here are some options: Insert a gloved hand into the vagina and gently push the fetal presenting part away from the cord. Place the woman in Trendelenburg position to tilt the presenting part backward into the pelvis and relieve pressure on the cord. Administer oxygen to the mother by face mask to improve oxygen flow to the fetus. If the cord has prolapsed to the point that it’s visible outside the vagina, don’t attempt to push the cord back in. This can add to the compression and may cause kinking. Cover the exposed portion with a compress soaked with sterile saline solution to prevent drying, which could result in atrophy of the umbilical vessels. Persevere if it isn’t clear Normal amniotic fluid is clear. Bloody or meconium-stained amniotic fluid is considered abnormal and requires careful, continuous monitoring of the mother and fetus. Bloody amniotic fluid may indicate a bleeding problem. Meconium-stained amniotic fluid may indicate fetal distress. If the fluid is meconium-stained, note whether the staining is thin, moderate, thick, or particulate. Take a whiff Amniotic fluid has a scent described as either a sweet smell or odorless. A foul smell indicated the presence of an infection and the patient needs further evaluation. Prolapse potential Amniotomy increases the risk to the fetus because there’s a possibility that a portion of the umbilical cord will prolapse with the amniotic fluid. Fetal heart rate (FHR) should be monitored during and after the procedure to make sure that umbilical cord prolapse didn’t occur. (See Complications of amniotomy , page 309 .) Oxytocin administration Synthetic oxytocin (Pitocin) is used to induce or augment labor. It may be used in patients with gestational hypertension, prolonged gestation, maternal diabetes, Rh sensitization, premature or prolonged rupture of membranes, and incomplete or inevitable abortion. Oxytocin is also used to evaluate for fetal distress after 31 weeks’ gestation and to control bleeding and enhance uterine contractions after the placenta is delivered. Oxytocin is always administered I.V. with an infusion pump. Throughout administration, FHR and uterine contractions should be assessed, monitored, and documented according to National Institutes of Child Health and Human Development (NICHD) criteria. First things first Prior to the start of an infusion you should have at least a 15-minute strip of both FHR and uterine activity to establish a reassuring FHR. There also should be a Bishop score documented as a measure of ensuring the cervix is ripe for labor. Additionally, a set of maternal vital signs should also be obtained. Nursing interventions Here’s how to administer oxytocin: Start a primary I.V. line. Insert the tubing of the administration set through the infusion pump, and set the drip rate to administer the oxytocin at a starting infusion rate of 0.5 to 2 mU/minute. The maximum dosage of oxytocin is 20 mU/minute. Typically, oxytocin is diluted 10 units in 500 ml or 20 units in 1,000 ml of an isotonic solution; lactated Ringer is the most common. This dilution results in a dosage of 2 mU/minute for every 3 ml/hour of I.V. fluid infused. An alternative dosing is 30 units diluted in 500 ml and the dosage becomes 1 mU/minute for every 1 ml/hour of I.V. fluid infused. Piggyback ride The oxytocin solution is then piggybacked to the primary I.V. line, through the lowest possible access point on the I.V. tubing. If a problem occurs, such as a nonreassuring FHR pattern or uterine tachysystole, stop the piggyback infusion immediately and resume the primary line. Immediate action Because oxytocin begins acting immediately, be prepared to start monitoring uterine contractions. Increase the oxytocin dosage as ordered—but never increase the dose more than 1 to 2 mU/minute every 15 to 60 minutes. Typically, the dosage continues at a rate that maintains a regular pattern (uterine contractions occur every 2 to 3 minutes lasting less than 2 minutes duration). If more is in store Before each increase, be sure to assess contractions, maternal vital signs, fetal heart rhythm, and FHR. If you’re using an external fetal monitor, the uterine activity strip or grid should show contractions occurring every 2 to 3 minutes. The contractions should last for about 60 seconds and be followed by uterine relaxation. If you’re using an internal uterine pressure catheter (IUPC), look for an optimal baseline value ranging from 5 to 15 mm Hg. Your goal is to verify uterine relaxation between contractions. Assist with comfort measures, such as repositioning the patient on her other side, as needed. Following through Continue assessing maternal and fetal responses to the oxytocin. Maternal assessment should include blood pressure, pulse, and a pain assessment Review the infusion rate to prevent uterine tachysystole. To manage tachysystole, discontinue the infusion and administer oxygen. (See Complications of oxytocin administration , page 312 .) To reduce uterine irritability, try to increase uterine blood flow. Do this by changing the patient’s position and increasing the infusion rate of the primary I.V. line. After tachysystole resolves, resume the oxytocin infusion per your facility’s policy. Advice from the experts Complications of oxytocin administration Oxytocin can cause uterine tachysystole. This, in turn, may progress to tetanic contractions, which last longer than 2 minutes. Signs of tachysystole include contractions that are less than 2 minutes apart and last 90 seconds or longer, uterine pressure that doesn’t return to baseline between contractions, and intrauterine pressure that rises over 75 mm Hg. What else to watch for Other potential complications include fetal distress, abruptio placentae, uterine rupture, and water intoxication. Water intoxication, which can cause maternal seizures or coma, can result because the antidiuretic effect of oxytocin causes decreased urine flow. Stop signs Watch for the following signs of oxytocin administration complications. If any indication of any potential complications exists, stop the oxytocin administration, administer oxygen via face mask, and notify the doctor immediately. Fetal distress Signs of fetal distress include: late decelerations bradycardia. Abruptio placentae Signs of abruptio placentae include: sharp, stabbing uterine pain pain over and above the uterine contraction pain heavy bleeding hard, boardlike uterus. Also watch for signs of shock, including rapid, weak pulse; falling blood pressure; cold and clammy skin; and dilation of the nostrils. Uterine rupture Signs of uterine rupture include: sudden, severe pain during a uterine contractions tearing sensation absent fetal heart sounds. Also watch for signs of shock, including rapid, weak pulse; falling blood pressure; cold and clammy skin; and dilation of the nostrils. Water intoxication Signs and symptoms of water intoxication include: headache and vomiting (usually seen first) hypertension peripheral edema shallow or labored breathing dyspnea tachypnea lethargy confusion change in level of consciousness. Ripening agent application If a woman’s cervix isn’t soft and supple, a ripening agent may be applied to it to stimulate labor. Drugs containing prostaglandin E 2 —such as dinoprostone (Cervidil, Prepidil, Prostin E2)—are commonly used to ripen the cervix. These drugs initiate the breakdown of the collagen that keeps the cervix tightly closed. The ripening agent can be: applied to the interior surface of the cervix with a catheter or suppository applied to a diaphragm that’s then placed against the cervix inserted vaginally. Additional doses may be applied every 3 to 6 hours; however, two or three doses are usually enough to cause ripening. The woman should remain flat after application to prevent leakage of the medication. Success half the time The success of this labor stimulation method varies with the agent used. After just a single application of a ripening agent, about 50% of women go into labor spontaneously and deliver within 24 hours. Those women who don’t go into labor require a different method of labor stimulation. Prostaglandin should be removed before amniotomy. Use this drug with caution in women with asthma, glaucoma, and renal or cardiac disease. Not to be ignored Prior to application of the ripening agent, a 15-minute strip of FHR and uterine activity should be completed as a baseline. Although the ripening agent is applied, carefully monitor the patient’s uterine activity. If uterine tachysystole occurs or if labor begins, the prostaglandin agent should be removed. The patient should also be monitored for adverse effects of prostaglandin application, including headache, vomiting, fever, diarrhea, and hypertension. FHR and uterine activity should be monitored continuously between 30 minutes and 2 hours after vaginal insertion, dependent upon the agent used. Onset of labor True labor begins when the woman has bloody show, her membranes rupture, and she has painful contractions of the uterus that cause effacement and dilation of the cervix. The actual mechanism that triggers this process is unknown. Before the onset of true labor, preliminary signs appear that indicate the beginning of the birthing process. Although not considered to be a true stage of labor, these signs signify that true labor isn’t far away. Preliminary signs and symptoms of labor Preliminary signs and symptoms of labor include lightening, increased level of activity, Braxton Hicks contractions, and ripening of the cervix. Subjective signs, such as restlessness, anxiety, and sleeplessness, may also occur. (See Labor: True or false?) Lightening Lightening is the descent of the fetal head into the pelvis. The uterus lowers and moves into a more anterior position, and the contour of the abdomen changes. In primiparas, these changes commonly occur about 2 weeks before birth. In multiparas, these changes can occur on the day labor begins or after labor starts. More pressure here, less pressure there Lightening increases pressure on the bladder, which may cause urinary frequency. In addition, leg pain may occur if the shifting of the fetus and uterus increases pressure on the sciatic nerve. The mother may also notice an increase in vaginal discharge because of the pressure of the fetus on the cervix. However, breathing becomes easier for the woman after lightening because pressure on the diaphragm is decreased. Advice from the experts Labor: True or false? Use this chart to help differentiate between the signs and symptoms of true labor and those of false labor. Signs and symptoms True labor False labor Cervical changes Cervix softens and dilates No cervical dilation or effacement Level of discomfort Intense Mild Location of contractions Start in the back and spread to the abdomen Abdomen or groin Uterine consistency when palpated Hard as a board; can’t be indented Easily indented with a finger Regularity of contractions Regular with increasing frequency and duration Irregular; no discernible pattern; tends to decrease in intensity and frequency with activity Frequency and duration of contractions affected by position or activity No Yes Ruptured membranes Possible No Increased level of activity After having endured increased fatigue for most of the third trimester, it’s common for a woman to experience a sudden increase in energy before true labor starts. This phenomenon is sometimes referred to as “nesting” because, in many cases, the woman directs this energy toward last-minute activities, such as organizing the baby’s room, cleaning and straightening her home, and preparing other children in the household for the new arrival. A built-in energy source The woman’s increase in activity may be caused by a decrease in placental progesterone production (which may also be partly responsible for the onset of labor) that results in an increase in the release of epinephrine. This epinephrine increase gives the woman extra energy for labor. Braxton Hicks contractions Braxton Hicks contractions are mild contractions of the uterus that occur throughout pregnancy. They may become extremely strong a few days to a month before labor begins, which may cause some women, especially a primipara, to misinterpret them as true labor. Several characteristics, however, distinguish Braxton Hicks contractions from labor contractions. Patternless Braxton Hicks contractions are irregular. There’s no pattern to the length of time between them and they vary widely in their strength. They gradually increase in frequency and intensity throughout the pregnancy, but they maintain an irregular pattern. In addition, Braxton Hicks contractions can be diminished by increasing activity or by eating, drinking, or changing position. Labor contractions can’t be diminished by these activities. Painless Braxton Hicks contractions are commonly painless—especially early in pregnancy. Many women feel only a tightening of the abdomen in the first or second trimester. If the woman does feel pain from these contractions, it’s felt only in the abdomen and the groin—usually not in the back. This is a major difference from the contractions of labor. No softening or stretching Probably, the most important differentiation between Braxton Hicks contractions and true labor contractions is that Braxton Hicks contractions don’t cause progressive effacement or dilation of the cervix. The uterus can still be indented with a finger during a contraction, which indicates that the contractions aren’t efficient enough for effacement or dilation to occur. Ripening of the cervix Ripening of the cervix refers to the process in which the cervix softens to prepare for dilation and effacement. It’s thought to be the result of hormone-mediated biochemical events that initiate breakdown of the collagen in the cervix, thus causing it to soften and become flexible. As the cervix ripens, it also changes position by tipping forward in the vagina. Ripening of the cervix doesn’t produce outwardly observable signs or symptoms. The ripeness of the cervix is determined during a pelvic examination, usually in the last weeks of the third trimester. Signs of true labor Signs of true labor include uterine contractions, bloody show, and spontaneous rupture of membranes. Uterine contractions The involuntary uterine contractions of true labor help effacement and dilation of the uterus and push the fetus through the birth canal. Although uterine contractions are irregular when they begin, as labor progresses they become regular with a predictable pattern. Early contractions occur anywhere from 5 to 30 minutes apart and last about 30 to 45 seconds. The interval between the contractions allows blood flow to resume to the placenta, which supplies oxygen to the fetus and removes waste products. As labor progresses, the contractions increase in frequency, duration, and intensity. During the transition phase of the first stage of labor—when contractions reach their maximum intensity, frequency, and duration— they each last 60 to 90 seconds and recur every 2 to 3 minutes.

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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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If Kate Middleton Misses Wimbledon, Officials May Tap This Royal Family Member for Top Job

As patron of the All England Lawn Tennis and Croquet Club, the Princess of Wales traditionally hands out trophies to the tennis tournament's winners

Janine Henni is a Royals Staff Writer for PEOPLE Digital, covering modern monarchies and the world's most famous families. Like Queen Elizabeth, she loves horses and a great tiara moment.

Simon Bruty/Anychance/Getty 

While Kate Middleton 's Wimbledon plans this year remain unclear, the tennis tournament has reportedly "earmarked" another member of the royal family to distribute trophies in her stead.

On July 8, The Telegraph reported that Birgitte, the Duchess of Gloucester may present trophies at the finals this weekend if Princess Kate, who is continuing to undergo treatment for cancer , is unavailable. As patron of the All England Lawn Tennis and Croquet Club, a royal role she received from Queen Elizabeth in 2016, Princess Kate wears a special bow pin to Wimbledon in the club’s colors (dark green and purple) and traditionally presents prizes to the champions.

The Duchess of Gloucester, 78, is married to Queen Elizabeth 's first cousin  Prince Richard , the Duke of Gloucester.

Like Kate, Birgitte is an avid tennis fan with a related patronage. The Duchess of Gloucester has been an Honorary President of the Lawn Tennis Association for 25 years, supporting the governing body for tennis in Great Britain. This year, the Duchess of Gloucester has attended the tennis tournament twice since the competition began on July 1.

She is a full-time working member of the royal family and recently made royal history with her investiture as a Royal Lady of the Most Noble Order of the Garter, becoming the first non-blood royal who is not married to the monarch or the heir to the throne to be appointed to the position.

Julian Finney/Getty

Dedicated tennis player Princess Kate has attended Wimbledon every year since she married Prince William in 2011, except for the 2013 matches shortly before the birth of Prince George .

The update on the awards ceremony comes after All England Club chair Debbie Jevans told Telegraph Sport last month that they would give the Princess of Wales, 42, "as much flexibility as possible" regarding the possibility of trophy presentation amid her cancer treatment. 

"We’re hopeful that the Princess of Wales will be able to present the trophies as the Club’s patron, but her health and recovery is the priority," Jevans told the outlet in a piece published on June 27. "We don’t know what we don’t know. All we’ve said is that we’ll work with her and give her as much flexibility as possible."

Telegraph Sport previously reported that the decision on who will present the trophies may not be made until the morning of the finals.

Shi Tang/Getty 

Princess Kate made her first and only public appearance this year at Trooping the Colour on June 15, joining her family for King Charles ' official birthday parade in London. 

The Princess of Wales revealed her plans to attend Trooping in a personal letter released the day prior, in a message significant as the first update on her health since she announced on March 22 that she has cancer and is undergoing chemotherapy.

"I’m looking forward to attending the King’s Birthday Parade this weekend with my family and hope to join a few public engagements over the summer, but equally knowing I am not out of the woods yet," the Princess of Wales said in part. "I am learning how to be patient, especially with uncertainty. Taking each day as it comes, listening to my body and allowing myself to take this much-needed time to heal."

Benjamin Cremel/AFP/Getty

Princess Kate spoke openly about her experience with chemotherapy in the letter, describing the difference between "good days" and "bad days."

"I am making good progress, but as anyone going through chemotherapy will know, there are good days and bad days. On those bad days you feel weak, tired and you have to give in to your body resting. But on the good days, when you feel stronger, you want to make the most of feeling well," she said. 

"My treatment is ongoing and will be for a few more months," she added of what's ahead. "On the days I feel well enough, it is a joy to engage with school life, spend personal time on the things that give me energy and positivity, as well as starting to do a little work from home."

No decisions have been made about what future engagements the royal might make in the coming weeks. Any upcoming outings will be based on when Princess Kate feels able and with the support of her medical team. 

Wimbledon has long been a highlight on the Princess of Wales' summer calendar, and she attended three days of the tournament in July 2023. The Princess of Wales presented the trophies at the Women's Singles Final and Men's Singles Final last summer, the latter of which she watched from the Royal Box with Prince William, Prince George, 10, and Princess Charlotte , 9.

Charlotte Wilson/Offside/Offside/Getty

Can't get enough of PEOPLE's Royals coverage? Sign up for our free Royals newsletter to get the latest updates on Kate Middleton, Meghan Markle and more!

Princess Kate's parents Carole and Michael Middleton attended Wimbledon on July 4, and the royal hinted that she's following the Grand Slam championship from home in a rare social media message on July 6.

Over the weekend, Princess Kate penned a message for Andy Murray after his Wimbledon career came to a close after his mixed doubles partner Emma Raducanu withdrew due to wrist soreness. 

"An incredible Wimbledon career comes to an end. You should be so very proud @andymurray. On behalf of all of us, thank you!" the Princess of Wales wrote on social media on July 6 in a message shared to the official Instagram and X accounts she shares with Prince William. She signed the note "C" for Catherine, the shorthand signaling that the note came directly from her.

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WATCH: Biden holds news conference after NATO summit

WASHINGTON (AP) — President Joe Biden used his highly anticipated news conference Thursday to deliver a forceful defense of his foreign and domestic policies and batted away questions about his ability to serve another four years, declaring: “I’m not in this for my legacy. I’m in this to complete the job.”

Watch the event in our player above.

Early on, he made one notable flub when he bobbled a reference to Vice President Kamala Harris. But for an hour he largely held his own under intense questioning, eschewing any suggestion that he was in decline, no longer capable of leading the nation and too old to serve another term.

It was unclear whether the performance was enough to change the dynamic that has set in with a growing number of Democratic lawmakers, donors and celebrities calling on him to step aside while Biden digs in, insisting he’s staying in the race and will win come November.

WATCH: Biden faces major public test as more Democrats call for him to step aside

“If I slow down and I can’t get the job done, that’s a sign that I shouldn’t be doing it,” Biden said. “But there’s no indication of that yet — none.”

Yet even as he wrapped his news conference, Biden was confronting calls to step aside. In a statement released shortly after he walked offstage, Connecticut Rep. Jim Himes, the top Democrat on the House Intelligence Committee, said Biden should end his candidacy, considering his “remarkable legacy in American history.” A dozen other House Democrats have called on him to make way for a new candidate.

Democrats are locked in a standoff with the president over his reelection following his disastrous debate performance two weeks earlier. The 81-year-old has explained away his performance as a bad night following a grueling month of international travel. He’s been out in public more, talking with voters and answering reporters’ questions. He even looks considerably less pale than he did on June 27.

But the calls to step aside keep coming. And the longer the infighting continues, the less the Democrats are presenting a united front against Donald Trump.

“I’m determined on running but I think it’s important that I allay fears — let them see me out there,” Biden said.

In his first exchange with reporters, Biden was asked about losing support among many of his fellow Democrats and unionists, and was asked about Vice President Kamala Harris. Biden was at first defiant, saying the “UAW endorsed me, but go ahead,” meaning the United Auto Workers. But then he mixed up Harris and Trump, saying, “I wouldn’t have picked Vice President Trump to be vice president if she wasn’t qualified.”

Trump weighed in live on Biden’s news conference with a post on his social media network of a video clip of the president saying “Vice President Trump.”

Trump added sarcastically, “Great job, Joe!”

Most of the hourlong press conference was vintage Biden: He gave long answers on foreign policy and told well-worn anecdotes. He used teleprompters for his opening remarks on NATO, which ran about eight minutes. Then the teleprompters lowered and he took a wide range of questions from 10 journalists about his mental acuity, foreign and domestic policy and — mostly — the future of his campaign.

“I believe I’m the best qualified to govern. I believe I’m the best qualitied to win,” Biden said, adding that he will stay in the race until his staff says, “There’s no way you can win.”

“No one’s saying that,” he said. “No poll says that.”

Earlier, Biden’s campaign laid out what it sees as its path to keeping the White House in a new memo, saying that winning the “blue wall” states of Wisconsin, Pennsylvania and Michigan is the “clearest pathway” to victory. And it declared no other Democrat would do better against Trump.

WATCH: Democratic strategist warns changing presidential nominee ‘is not cost-free’

“There is also no indication that anyone else would outperform the president vs. Trump,” said the memo from campaign chair Jen O’Malley Dillon and campaign manager Julie Chavez Rodriguez that was obtained by The Associated Press.

The memo sought to brush back “hypothetical polling of alternative nominees ” as unreliable and it said such surveys “do not take into account the negative media environment that any Democratic nominee will encounter.”

Meanwhile, the campaign has been quietly surveying voters on Harris to determine how she’s viewed among the electorate, according to two people with knowledge of the campaign who spoke to the AP on condition of anonymity to talk about internal matters.

The people said the polling was not necessarily to show that she could be the nominee in Biden’s place, but rather to better understand how she’s viewed. The research came after Trump stepped up his attacks against Harris following the debate, according to another person familiar with the effort. The survey was first reported by The New York Times.

While Biden has expressed confidence in his chances, his campaign on Thursday acknowledged he is behind, and a growing number of the president’s aides in the White House and the campaign privately harbor doubts that he can turn things around.

But they’re taking their cues from Biden, expressing that he is in 100 percent unless and until he isn’t, and there appears to be no organized internal effort to persuade the president to step aside. His allies were well aware heading into the week there would be more calls for him to step down, and they were prepared for it.

But in announcing a compact that would bring together NATO countries to support Ukraine, Biden referred to the nation’s leader Volodymyr Zelenskyy as “President Putin” to audible gasps in the room. He quickly returned to the microphone: “President Putin — he’s going to beat President Putin … President Zelenskyy,” Biden said.

Then he said, “I’m so focused on beating Putin,” in an effort to explain the gaffe.

“I’m better,” Zelenskyy replied. “You’re a hell of a lot better,” Biden said back.

WATCH: German Chancellor Scholz on NATO’s future, supporting Ukraine and working with Biden

Senate Majority Leader Chuck Schumer invited Biden’s team to meet with senators privately at the lunch hour to discuss concerns and the path forward, but some senators groused they would prefer to hear from the president himself. In the Senate, only Peter Welch of Vermont has so far called for Biden to step out of the race.

The 90-minute conversation with the president’s team, which one person said included no new data, polling or game plan on how Biden would beat Trump, did not appear to change senators’ minds. The person was granted anonymity to discuss the closed door session.

The meeting was frank, angry at times and also somewhat painful, since many in the room know and love Biden, said one senator who requested anonymity to discuss the private briefing. Senators confronted the advisers over Biden’s performance at the debate and the effect on Senate races this year

One Democrat, Sen. Chris Murphy of Connecticut, said afterward, “My belief is that the president can win, but he’s got to be able to go out and answer voters’ concerns. He’s got to be able to talk to voters directly over the next few day.”

At the same time, influential senators are standing strongly with Biden, leaving the party at an impasse.

Sen. Bernie Sanders, the Vermont independent, told the AP he thinks Biden “is going to win this election. I think he has a chance to win it big.”

Sanders said he has been publicly critical of the campaign, and said Biden needs to talk more about the future and his plans for the country. “As we come closer to Election Day, the choices are very clear,” he said.

Associated Press writers Zeke Miller, Seung Min Kim, Lisa Mascaro, Colleen Long, Michael Balsamo, Mary Clare Jalonick, Kevin Freking, Farnoush Amiri and Linley Sanders contributed to this report.

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Trump assassination attempt: Graphics, maps show you what happened

An investigation continues into the attempted assassination of former President Donald Trump at a rally in Bulter, Pennsylvania, on Saturday, in which one attendee was shot and killed and two others seriously injured.

The gunman was shot and killed by Secret Service agents. The FBI later identified him as Thomas Matthew Crooks , 20, of Bethel Park, Pennsylvania, about 40 miles south of Butler. His motive is not yet known.

Details continue to emerge. Trump says a bullet pierced the upper part of his right ear before Secret Service agents hustled him off the stage and into a limousine. He was reported to be otherwise unharmed.

The gunman, who is believed to have acted alone, fired at the rally stage from a building rooftop about 150 yards away, outside the rally's security perimeter. Agents recovered an AR-style rifle from the scene.

Here is what we know at the moment. All times are Eastern:

Where was Trump?

1 p.m.: The Butler Farm Show, site of the rally, opens its doors to attendees. Trump is scheduled to speak at 5 p.m.

6:03 p.m.: Trump takes the stage and greets the crowd as the Lee Greenwood song “God Bless the USA” plays.

6:05 p.m.:  The song ends, and Trump begins speaking.

Unable to view our graphics? Click here to see them.

6:11 p.m.: While Trump is speaking, multiple shots are fired toward the stage. Videos show Trump grabbing his right ear, looking at his bloody hand and dropping to the ground behind the podium. People can be heard saying, "Shots, shots, shots."

6:12 p.m.: Secret Service agents jump on top of Trump and escort him off stage and into a vehicle. Trump gives a thumbs up as he leaves.

How many shots were fired?

6:14 p.m.: Trump's motorcade leaves the fairgrounds surrounded by law enforcement vehicles.

6:42 p.m.: The Secret Service  issues a statement confirming “an incident”  took place at the rally and that Trump “is safe.” Shortly after, the Trump campaign issues a statement saying Trump “is fine and is being checked out at a local medical facility."

7:24 p.m.: The Butler County district attorney says the suspected shooter is dead and one rally attendee has been killed, the Associated Press reports.

Where was the shooter?

7:49 p.m.: Secret Service spokesman Anthony Guglielmi  releases a statement  saying agents neutralized the shooter and that he was dead. The statement says one person was killed and two spectators have been seriously injured.

8:13 p.m.: In a short televised briefing, President Joe Biden says he was trying to call Trump  to speak with him as soon as possible.

8:42 p.m.: Trump posts on Truth Social confirming he was shot :

• “It is incredible that such an act can take place in our Country. Nothing is known at this time about the shooter, who is now dead. I was shot with a bullet that pierced the upper part of my right ear. I knew immediately that something was wrong in that I heard a whizzing sound, shots, and immediately felt the bullet ripping through the skin. Much bleeding took place, so I realized then what was happening. GOD BLESS AMERICA!"

9:33 p.m.: The FBI's Pittsburgh office says it has assumed the lead in the shooting investigation.

11:52 p.m.: In a news conference, Kevin Rojek, special agent in charge of the Pittsburgh FBI office, says the shooting was an attempted assassination of Trump and that investigators are working to determine a motive.

Who shot Trump? What gun was used?

Sunday: Law enforcement sealed off the home of Thomas Matthew Crooks for investigation.

Crooks used a legally-purchased "AR-style 556 rifle," said Kevin Rojek, a special agent in charge of the FBI's Pittsburgh field office, on a call with reporters. The agent likely refers to a rifle that fires 5.56 mm ammunition, though there are some firearm models with "556" in their name.

The weapon was located next to Crooks on the scene, Rojek said.

Rojek said law enforcement located "a suspicious device" when they searched the Crooks' vehicle. The device is being analyzed at the FBI crime lab in Quantico, Virginia.

Agents also obtained a court order to examine Crooks' cellphone in hopes its contents will provide clues into the shooting.

"At this time, the information that we have indicates that the shooter acted alone and that there are currently no public safety concerns," Rojek said. Another unidentified official on the call said the FBI believes the weapon was bought by the shooter's father. The family is cooperating with the investigation, officials said.

More coverage:

Trump rally shooting victims: Pennsylvania firefighter killed, 2 local residents wounded

Read more : Trump rally shooter Thomas Crooks appears to have acted alone, used 'AR-style 556' rifle: FBI

Nursing aide turned sniper : Thomas Crooks' mysterious plot to kill Trump

CONTRIBUTING Natalie Neysa Alund and Aysha Bagchi, USA TODAY.

SOURCE USA TODAY Network reporting and research; Reuters

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How to compete and win with your listing presentation (+ scripts)

Win your next listing by acing the fundamentals of the listing appointment, including a knockout listing presentation

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In this article, I’ll share close to two decades of experience as a licensed agent and small brokerage owner in Boston to help you compete and win listings with a dynamite listing presentation. As agents, we compete for a finite number of available homes to list and sell. That’s why it’s crucial that you stand out amongst your competitors to get those listings.

The real estate listing presentation is one of the most critical tools in your arsenal for demonstrating your knowledge, expertise, experience, and above all — your authenticity. A well-done listing presentation not only distinguishes you from your competitors — it also elevates the seller’s experience of working with you from day one. It may sound cliché, but you never get a second chance to make a first impression. We break it down for you, sharing how to create a knockout listing presentation AND how to crush your next listing appointment.

• Research market data
• Prepare a pricing strategy
• Prepare your pitch
• Update your listing presentation 
• Prepare for your listing appointment  
• Set the stage for success
• Actively listen
• Be honest & authentic
• Conduct a needs analysis  
• Demonstrate your value
• Share your market analysis
• Present your marketing strategy
• Discuss pricing strategy
• Reiterate your value proposition
• Close the deal

The full picture: How to win more listings with a knockout listing presentation

How to create a knockout listing presentation in 5 steps.

Creating a knockout listing presentation requires detailed research, solid data, market knowledge, marketing acumen, organizational skills and excellent design to clearly communicate all the information you want to share with your client. We’ll walk you through the steps to creating an impressive, concise, and attractive listing presentation document, which you can present in hard copy or digital format.

Step 1. Research market data

Your work begins once you and your client have set an appointment to meet. It’s crucial for you to know the market and understand the numbers. Your local MLS and association can help you find these crucial data points. You may also want to research the client on social media to understand their needs and circumstances. What is their family size? How long have they lived in the home? Here’s a checklist of information you should include in your listing presentation (or have on hand when you arrive at the listing appointment). Find out the answers to these questions before you arrive so you can come armed with all the necessary information.

• Market Inventory: What is the current market and micro-market inventory?
• Days on Market: How long does it take for properties to sell? Understand Days on Market (DOM) in the area
• Average Sales Price: What are the average selling prices for similar properties in the area
• Property Costs: Understand the property’s current HOA fees, property taxes, and other costs
• School District: Look up the school district and local schools
• Walkability Score: Research the area’s walkability score
• Market Type: What type of market are you in? (Seller / Buyer/ Balanced). Numbers and market types can differ locally, regionally and nationally and it is helpful to be able to communicate how your market compares and fits into a broader context.

Step 2. Prepare a pricing strategy

Many sellers think they understand pricing as well as you do. It’s important to do your research and determine the selling price of the property yourself.

Pricing properties is not an exact science, but there are pricing strategies you can apply to help get you there. The first is on a macro-level and considers market conditions. Understanding the type of market you’re in and the current inventory are significant pieces of information that can help you determine the selling price of a property. You may find it easier to discuss pricing with sellers if you can explain current market conditions. You can find the data to determine the market type in your local MLS. The three different types of markets, based on inventory, are:

• Seller’s Market – Less than six months of inventory in the area. Key indicators of this type of market are multiple offers and properties that sell very quickly.
• Balanced Market – Six months of housing inventory in the area. There is no advantage to either buyers or sellers in this type of market.
• Buyer’s Market – Greater than six months’ worth of inventory in the area. There are usually many properties available at different price points in a buyer’s market and properties generally take longer to sell. Listings often receive offers under the asking price from buyers.

Another important pricing strategy on the micro-level involves understanding the “comps” or comparable properties that are currently listed or that have recently sold in your client’s area. This can be accomplished by preparing a full Comparative Market Analysis (CMA) , or it can be a less formal conversation about comps at your listing appointment. Alternatively, you can make it an addendum to your listing presentation to be added at a later date, after you’ve viewed the home at the listing appointment (more on where and when that should be held later!).

Step 3. Prepare your pitch

It’s important to have your “elevator pitch” ready. Developing and communicating this pitch is essential to your listing presentation. We refer to this as your value proposition and it’s a unique, very concise statement about what you offer your clients and why they should choose you — in one or two sentences.

While you may feel challenged to develop your value proposition, it may be easier than you think! One strategy is to look at your past client or employment reviews (if you’re new to the business) and circle the descriptive words that others use about you, like “communicates well,” “hard worker,” or “knowledgeable.” You will likely see a pattern in how others describe you, and you can use those descriptors to help define and create your unique value proposition. 

Step 4. Update your listing presentation 

Designing a winning listing presentation may seem challenging, but you don’t need to reinvent the wheel! Many resources and templates are available (both free and paid) to help you design a knockout listing presentation. Most large real estate brokerages have tools available for agents already branded with logos and colors and ready for you to input your information. Smaller brokerages may not provide the same, but you can find easy-to-use, customizable real estate listing presentation templates online: 

• Breakthrough Broker

The real estate market fluctuates and constantly changes and so should you. When those changes happen, you need to be mindful of how recent market changes need to be communicated in your listing presentation and you must adapt accordingly. Updating your presentation before each listing appointment is a surefire way to ensure that your information and presentation remain accurate and impactful as possible. 

Step 5. Prepare for your listing appointment 

Aside from your winning personality, don’t forget to bring these items with you to your appointment:

• A professionally presented real estate listing presentation: Bring enough copies for all sellers to review.
• Pre-filled listing paperwork: Prepare the listing paperwork both digitally and in hard copy. Most information can be pre-filled prior to the presentation.
• A fully charged tablet or computer if you are presenting digitally: Remember that technology doesn’t always work the way you expect it to. Additionally, digital presentations can sometimes be awkward depending on the setting or location, or if you are presenting to more than one person. Always be prepared with hard copies even if you are expecting to present on your tablet or computer.
• A pen: Some sellers still use them and you may need one to sign the paperwork.

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How to crush your listing appointment in 10 steps

What does a successful listing appointment look like? The goal of a successful listing appointment is to win the listing and walk away with a signed contract in hand. It’s that simple. As an agent, you are a facilitator of the home-selling process. The most important thing to remember about the listing appointment, your listing presentation and the entire selling process is that it’s about the seller — not you. Here’s how you can crush every listing appointment and leave with a signed contract.

Step 1: Set the stage for success

Real estate agents are famous for selling the importance of location, location, location . The location of your listing appointment sets the stage for your successful listing presentation, and the best opportunity for you to see the home is when you’re making your pitch. That’s why your listing appointment should always take place at the seller’s home. While it seems that everything can be done online these days — this can’t. You must see the home to accurately assess it and offer valuable advice to the homeowners.

Step 2: Actively listen

While highlighting your skills and experience is important to establish your credibility and success, a key portion of your listing appointment should be spent listening carefully to the seller. Following the rule of listening twice as much as you speak will always pay off in your listing presentations.

Always keep in mind that selling a home is often a highly emotional experience for the seller. It can be happy, sad, exciting or a tangle of conflicting emotions. Sellers want to feel heard and will almost always tell you exactly what they want, need, or expect from their experience. If you listen — really listen — and genuinely strive to understand their motivations, needs, concerns and fears, you’ll be able to direct the conversation or adapt your presentation to better address their specific needs.

Pro tip: Listen twice as much as you speak to understand your client’s needs.

For example, a seller may tell you they want to sell their home quickly to relocate out of the country for a new job opportunity. In hearing and understanding those needs, you should focus your presentation on marketing, pricing, staging and other pre-market strategies that favor a faster timeline so you can list and sell their property quickly and efficiently.

Here’s a script you can use to kick off your real estate listing presentation:

Listing presentation script:

“I’m looking forward to sharing your wonderful home with the market and generating a pool of buyers who want to compete with each other for it. Let me show you how we can do that with a mix of advertising, marketing and leveraging our market share here in (local market).”

Step 3. Be honest & authentic 

An authentic agent who listens to sellers and always advises them honestly is a successful agent. Telling a seller something they don’t want to hear is uncomfortable, but you will earn their respect by being honest and forthcoming. Avoid oversharing information about yourself or becoming a storyteller in a listing presentation. Sure, you want to assure them of your skills and experience, but saying less about yourself (and again — listening more! ) can be much more impactful.

Step 4. Conduct a needs analysis 

This can be formal or informal, depending on your personal style. But if you’re actively listening, you can weave some of these questions into the conversation to help get to know the seller and their situation:

• What is your desired timeframe for listing and selling your home? 
• Are you looking to upgrade or downsize? 
• Are you relocating out of the state or the country?
• Is your timeframe dictated by the school year or a job?
• Do you have an idea of the pricing of your home? 
• What renovations or updates have you made that you believe could add value to your home?

Please remember that if the seller is not your client (yet!), you must advise them against sharing information you could inadvertently leverage against them if they choose another listing agent. Should you later bring forth a potential buyer, some of their answers to the questions here could compromise negotiations — so be sure to give them fair warning before delving too deep!

Step 5. Demonstrate your value

You can stand out with sellers by providing value and sharing information other agents may not have provided in their presentations (and you should always assume you’re not the only agent vying for their business!). Some examples of topics that you can discuss that provide unique value to your sellers:

• Safety – Many sellers don’t consider the potential dangers of opening their homes to strangers. I recommend that sellers secure or remove all medications, personal photos, small electronics, bills, financial papers, and any artwork that can identify them, including names from bedroom walls. This step is especially important if they have children. You’ll help your clients prevent theft, identity theft or other more serious crimes.
• Decluttering/staging – When touring the home as part of your presentation, provide decluttering and staging advice. While not every seller can afford professional staging, your recommendations can be invaluable in helping them prepare their property for sale.
• Repairs, renovations and updates – Discuss any repairs, renovations or updates (both big and small) that could significantly increase the selling price of your client’s home. Point out small repairs that can make a big difference, like fixing water stains on ceilings. Updating a bathroom might substantially add value to the selling price relative to the cost of the update. Conversely, some repairs, renovations or updates may not be worthwhile. Advising the client and boosting their selling price can help solidify you as a valuable and knowledgeable agent.

Pro tip: Listings can be won by providing information that no other agent has provided!

Step 6. share your market analysis.

Understanding the market and your ability to communicate clearly about it are two of the most vital skills of a successful real estate agent. Always be mindful of the changes in the market locally, regionally and nationally. Be sure that you also understand what is happening in the financial world with mortgage rates and other factors that may impact the market — and ultimately, your home seller’s transaction.

While understanding the current market is important, it is also crucial to understand the direction that the market could be headed in the coming months or year ahead. For instance, if mortgage rates are projected to increase within the coming months, sharing that information with your seller can help them make a more informed decision about listing their property. Here’s a timely example. Early this year, the National Association of REALTORS® announced the settlement of the Sitzer/Burnett Commission Lawsuit that will undoubtedly change the way that real estate commissions are handled. If you aren’t clearly explaining this settlement and what it means for sellers in your listing presentation, you’re not doing your job. Here is a script to help you communicate with your clients about buyer’s agent commissions:

Buyer’s agent commission script:

“(______), there are new changes in the real estate industry with respect to the payment of commissions for sellers agents and buyers agents. I would like to take a few moments to explain to you how this impacts you as you prepare to sell your home …”

Step 7. Present your marketing strategy 

Even in a highly active market, you should still have a comprehensive plan for marketing your seller’s property. Some ideas that can help you kickstart your listing marketing plan include: 

• Video marketing. Get creative with videos of your listings and post them to Facebook, Instagram Reels or YouTube. Try using drone footage for a unique perspective, but make sure to follow all local and federal aviation laws.
• QR codes + hot sheets. Create real estate flyers or virtual hot sheets for your listing and include a QR code so potential buyers can easily view a short video of the property’s highlights.
• Canvas the neighborhood . Knock on doors, call or leave flyers for neighbors and give them a sneak peek of your listing. 
• Facebook community groups. Spotlight your listing in groups that allow it (or start your own group) and share livestream videos (“lives”). Offer sneak previews to build interest in your listings. 
• Social media marketing : You don’t have to crush it on all platforms, but pick one or two, build an audience, and market your listings. Check out our 11 social media marketing strategies that work!

We love Coffee & Contracts because they deliver done-for-you, polished graphics and daily posts made to fit every social media channel — all for just $54 per month. Here’s what your Just Listed post might look like:

View this post on Instagram A post shared by Paige Steckling | Utah Real Estate Agent (@utahrealestatepaige)

You can also check out agent and coach Ashley Harwood’s foolproof marketing plan and template to help you determine which marketing activities yield the best results for you, and her advice on how to get more listings:

How to create a foolproof real estate marketing plan for 2024 (+ template)

How to get listings in real estate — 11 proven strategies for 2024

Download these 9 real estate prospecting letter templates that actually work

Step 8: discuss pricing strategy.

Sellers are more savvy than ever, and with countless online tools and resources available to them, most sellers already know the value of their home or how much they expect to sell it for before they sit down with you. While you may need to discuss pricing with them if you disagree with their number, agents spend much less time on this aspect of the listing presentation these days. However, it’s essential to set clear expectations at the outset. It may be challenging to discuss how a change in the market positions their property at a lower price point than they expect. However, that discussion is far better to have early rather than pricing their property inappropriately high and having it stagnate on the market. If you later need to lower their selling price, you’ve laid the groundwork for that discussion by pointing out the gap between their expectations and current market conditions.

Step 9: Reiterate your value proposition

Now that you’ve cleared the pricing hurdle, shared your expertise and market data, shown your client comps, toured the home and proven your value — it’s time to remind them of your elevator pitch. Circle back to the reasons this seller should hire you and only you to successfully list, market and sell their home. It’s important to be mindful of how they’re feeling, since selling a home and moving can signal big changes in their lives. A little empathy can go a long way here, and that’s a surefire way to cement your value proposition with any client. People want to work with people they like. While you may have cited your successes earlier in the meeting, now is the time to really focus on the client.

What do they need to move forward? How can you help make this big life change seamless and hassle-free for them? Be attentive, listen and show that you’re going to take care of them through this daunting process. After all, this may be the launchpad for a lifelong agent-client relationship.

Step 10: Close the deal

Ok, this is the tough part where you have to ask for your client’s business, bring out your prepared contract, and ask them to sign on the dotted line. As we said at the beginning, a successful real estate listing presentation ends with a signed contract . If you’re unsure how to broach the topic, you can use Boston-based listing agent and coach Ashley Harwood’s helpful and proven closing script to ask for your client’s business:

12 proven real estate scripts that boost confidence & earn more business

16 real estate prospecting strategies to supercharge your business

10 simple tips to master circle prospecting (+ scripts)

With the many tools and templates available to help agents create winning listing presentations — and armed with your value proposition, market and comps data — we’re confident that you can crush your upcoming listing appointments if you follow the advice we’ve shared here.

Remember: When you deliver your listing presentation to a seller, always listen to them as a trusted advisor, present yourself honestly and authentically, and accurately explain the market conditions to them. If you follow these steps, we’re confident you can leave your next listing appointment with a signed listing agreement. We’re rooting for you!

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