Challenges with Fetal Presentation: Breech, Face, Brow, and Transverse Lie Explained

Under ordinary conditions, the fetal presentation of an infant prior to delivery is in the cephalic (vertex) position. In the cephalic presentation, the infant’s head is situated in the lower portion of the mother’s abdomen, resulting in a baby that is born head-first. Some babies, however, are not in this position before delivery. In these instances, the baby’s abnormal presentations could put them at risk of umbilical cord issues and other birth traumas and complications.

Fetal Position vs Fetal Presentation 

In utero, a fetus has both a position and a presentation. The term “presentation” relates to the part of the infant’s body that is expected to come out of the birth canal first. For instance, if a newborn’s bottom is positioned to exit the birth canal first, the infant is in “breech presentation.” The term “position” relates to the direction the newborn is facing in regard to the mother’s spinal cord. A newborn could be positioned face-down against the spine, or face-up towards the stomach. 

What Should Fetal Presentation Be Before Delivery?

The preferred way for a baby to present for birth is vertex presentation. This is the presentation associated with the least amount of risk for vaginal births. In vertex presentation, the infant is situated head-first so that their occiput, the portion of their head that is closest to the base of their skull, enters the birth canal first. Vertex presentation allows the newborn’s chin to be tucked against its chest as it faces the mother’s spine (occipital-anterior position). Any position other than this is considered abnormal and could make a vaginal delivery extremely difficult or even, in some cases, impossible. If the baby’s chin is not folded down into its chest, he or she could be delivered face-first which can lead to a birth injury. 

Breech Presentation

Breech presentation is the expected presentation for most of the mother’s pregnancy. However, by week 37, the baby should have rotated on its own into the vertex position. A baby’s presentation is said to be breech when its legs or rear end are in a position to come through the birth canal first. Breech births can be dangerous because if a vaginal delivery is attempted, the baby is at a heightened risk for spinal cord fracture, traumatic head injury, prolapsed umbilical cord, death, and many other serious issues during the birthing process. 

There are four kinds of breech positions. They are:

• Footling breech: In this position, one or both of the baby’s feet enter the birth canal first. The baby’s bottom will also be positioned higher than the feet. 
• Kneeling breech: Kneeling breech is when the infant has one or both legs flexed at the knees and extended at the hips. 
• Frank breech: In this position, the baby’s butt is set to come out first. Their legs are extended at the knees and flexed at the hip. Their feet are also up by their ears
• Complete breech: When a baby is in complete breech, their knees and hips are flexed in such a way that they are sitting cross-legged, with their feet near their bottom. 

Complications of Breech Presentation

When a breech birth is mismanaged, it can lead to serious birth injuries, including: 

• Intracranial hemorrhages (brain bleeds)
• Hypoxic-ischemic encephalopathy
• Spinal cord fractures
• Cerebral palsy
• Seizures
• Developmental delays
• Intellectual disabilities

Face Presentation

Just as it sounds, face presentation takes place when the baby’s face is positioned to present first during delivery. In face position, the infant’s neck is extended backward (deflexed) so that the head is touching the back. This precludes head engagement and prevents the infant from descending the birth canal. In some instances, the trauma of a vaginal birth can lead to edema, which is the build-up of fluid in the baby’s upper airway and face, as well as facial deformation. Babies who are subjected to this often require a breathing tube in their airway to assist them with breathing and airway patency. 

Face presentations are divided into three categories:

• Mentum anterior: The chin faces the mother’s stomach.
• Mentum posterior: The chin is facing the mother’s back. This can cause the baby’s shoulders, neck, and head to enter the pelvis all at once. Most are not big enough to acclimate to this.  
• Mentum transverse:  The chin is turned to face the side of the birth canal.

Trauma is exceptionally commonplace when a baby in face presentation is delivered vaginally. Parents should be cautioned that their child might be bruised. To avoid this trauma, a C-section is needed. 

Complications of Face Presentation

When a face presentation birth is mismanaged, it can lead to severe birth injuries, such as: 

• Facial trauma
• Prolonged labor
• Upper airway and facial edema  
• Skull molding (an abnormally shaped head due to pressure on the infant’s head during delivery)
• Difficulty in ventilation or respiratory distress  
• Spinal cord damage
• Abnormal heart rate patterns
• Significant increase in fetal compromise
• Intracranial hemorrhages
• Hypoxic-ischemic encephalopathy
• Cerebral palsy
• Developmental delays
• Permanent brain damage
• Intellectual disabilities
• Seizures

Brow Presentation

Face presentation and brow presentation are very similar, but in brow presentation, the infant’s neck is not as extended. The chin of a baby in brow presentation is not tucked against their chest and their neck is extended backward only slightly. As the term indicates, the baby’s forehead is positioned to enter the pelvis first. Vaginal deliveries may be complicated or simply impossible because the presenting portion of the baby’s head is most likely too wide to fit safely through the mother’s pelvis.

Complications of Brow Presentation

When brow presentation is promptly diagnosed and properly managed, there are usually no lasting negative side effects for the mother or her child. If, however, a doctor fails to identify brow presentation and intercede in a timely manner, there could be permanent consequences for the baby. Newborns can experience oxygen deprivation caused by prolonged labor, or traumatic injuries due to a difficult delivery. Some of the more serious conditions brought about by a mismanaged brow presentation birth are:

• Cerebral palsy
• Hypoxic-ischemic encephalopathy
• Developmental disabilities
• Seizure disorders
• Periventricular leukomalacia

Transverse Lie (Shoulder Presentation) 

Transverse lie is when the baby’s trunk, shoulder, or arm descends the birth canal first. When a transverse lie position is detected during labor, a C-section is the safest method of delivery. Mothers with polyhydramnios (excess amniotic fluid), who have multiple gestations (twins, triplets, etc.), who have an infant with intrauterine growth restriction, or who have placenta previa, are at an increased risk of having a baby in the transverse lie position. After the membranes rupture, there is a heightened danger of umbilical cord prolapse, making a C-section the ideal form of delivery. 

Complications of Transverse Lie

Failure to deliver a baby in transverse lie promptly and by C-section can cause: 

• Severe birth asphyxia arising from cord compression  
• Hypoxic-ischemic encephalopathy
• Seizures
• Permanent brain damage
• Cerebral palsy

Did Abnormal Fetal Presentation Lead to Your Baby's Birth Injury?

If your child sustained a birth injury related to their fetal presentation and you are interested in pursuing financial compensation, consult with a Dallas birth injury lawyer from Rasansky Law Firm. We offer a free initial consultation and can advise you on how to best proceed with your birth injury case.