Parenting: Pregnancy

The world of pregnancy and labor has many unique terms, expressions – and decisions. From "Lamaze" and "epidural" to "dilation" and "episiotomy," the terms used by doctors, midwives and nurses can often get confusing. "Presentation" is one word doctors often use when speaking of an impending delivery. This term is important to the actual delivery process. Put simply, "presentation" is the position of the baby's body when progressing down the birth canal and entering the world or, in other words, how a baby presents itself during her entrance into the world.

"We refer to any presentation other than the normal as being 'fetal malpresentations,'" says Dr. David Michael, a specialist in obstetrics and gynecology at Mt. Sinai Hospital in Chicago. "The incidence of these malpresentations is only 5 percent of all births. Any deviation from the normal, big or small, is considered a malpresentation."

There are three components that indicate whether a baby is in a normal position or malpresentation. They include the fetal lie, which is the axis of the baby relative to that of the mother's; the presentation, which indicates what body part is closest to the pelvic outlet; and the flexion attitude, which refers to how the head of the baby is flexed. Each of these components has variations that indicate whether the baby is in a normal presentation position or is going to come through the birth canal in an unusual way.

The Fetal Lie
As a mother lies on her back during delivery, her spine is vertical – or straight up and down. In relation malpresentation, the fetal lie indicates the position of the baby's spine in relation to the mother's at the time of delivery. The "normal" spinal position is called "cephalic," meaning it is in the same direction and angle as the mother's spine. When the baby is positioned at an angle so that the spine is off–center from the mother's, the baby is said to have an "oblique lie," meaning it is at an angle away from the mother's spine. If the baby is lying in a position in which the mother's and the baby's spines make a cross or a "T" shape, the baby is in a "transverse lie."

Although rare, the malpresentation of a fetal lie could offer complications to the delivery process. "An oblique or transverse lie occurs in approximately one in 300 births," says Dr. Michael. "The major risk with a malpresentation of the fetal lie is that neither the feet or the head occupy the pelvic outlet, allowing an open space in the birth canal. Should a woman's water break, there is nothing plugging that outlet or taking up that space. The most common complication with a malpresentation of the fetal lie is cord prolapse."

"Cord prolapse" is when the umbilical cord exits the birth canal prior to the baby. If cord prolapse occurs, the blood and oxygen flow to the baby can be interrupted or severed, which can cause tissue, organ or brain damage.

"A cord prolapse can occur 20 times more often with a transverse lie than with an oblique or cephalic," Dr. Michael says. "If a mother goes into labor, especially if her water membrane breaks and she has been told by her doctor that her baby is in a transverse lie, she should get immediate medical attention or call 911. Women tend to have a good chance of having what is called an external cephalic reversion – where the doctor can turn the baby into a correct position. Also, a large percentage of the mothers whose babies are in an oblique or transverse lie will not need the doctor to help. When they go into labor and start contracting, oftentimes the baby will revert to a vertex presentation spontaneously. So by the time they are ready for actual delivery, the head will have made its way down into the pelvis on its own, lining up perfectly."

Presentation
Although the process in its entirety is also referred to as "presentation," one of the factors that contributes to the normal position or malpresentation of a baby during delivery is given the same term. The component of "presentation" refers to the part of the baby that first appears in the pelvis or birth canal. The typical presentation of a baby during delivery is the occipital lobe, or crown of the head, first. However, babies tend to come into the world in a wide variety of positions. In addition, there are several variations of each position.

Breech Presentation
A breech birth happens when a baby is born feet, knees or buttocks first. "Breech presentation occurs in 3 to 4 percent of all deliveries," says Dr. Michael. "So, if there were to be a malpresentation, it would more than likely be breech. Most babies can be breech as late as 32 weeks into the pregnancy and then move to a cephalic presentation during the last few weeks. If a woman has an ultrasound late in her pregnancy, up to 32 weeks and has been told her baby is in a breech position, there really is no cause for concern. Again, oftentimes babies in the breech position later in the pregnancy will turn themselves before labor and delivery begin – requiring no assistance from the doctor."

Judith Turner, a stay-at-home mother from Sandy, Utah, says, "My fifth baby was breech until a week before he was born – at 37 weeks. The plan was to either try to turn him when I went into labor or to try a vaginal breech delivery at the hospital instead of the birthing center. We discovered the previous day at an ultrasound that he had already flipped."

In the category of breech births, there are several positions a baby could take. These include Frank breech, complete breech, incomplete breech, footling and double footling. In the position of Frank breech, the baby is in a "V" position. The buttocks and pelvis are in the birth canal but the legs are flexed up over the baby's body. Complete breech is when the baby is sitting "Indian style," and incomplete breech is when the baby is sitting "Indian style" with one of the legs or feet dangling down. A footling position is when one of the feet is extended down toward the birth canal, and double footling is when both feet are extended down so that the first thing into the birth canal is the feet.

Compound Presentation
A compound presentation occurs when more than one part of the baby enters the pelvic outlet or birth canal at the same time. The most common compound presentation is the hand or arm alongside the head. The risk with a compound presentation is related to the size of the pelvis. If the pelvis is able to compensate for the extra room needed for a compound presentation, the doctor may allow the birth to occur naturally. However, if the cervix and pelvis are not able to compensate, an episiotomy – or a Cesarean section in extreme or emergency situations – may be performed.

Shoulder Presentation
Shoulder presentations are rare – less than one out of every 1,000 births – and require Cesarean section or repositioning before delivery can continue. "Shoulder births do not happen very often and when they do, most babies end up being delivered via C-section," Dr. Michael says. "There are very few doctors who will allow a shoulder presentation to go on naturally or who will attempt to reposition a shoulder presentation."

Flexion Attitude
The "flexion attitude" component of birth presentation refers to the position of the baby's head during delivery. The normal position of the baby's head should be in a chin-to-chest position, with the baby's face slightly downward as if attempting to touch the chin to the chest. When the head is at an angle as though the baby is looking up and the head is hyper-extended, it is called a "face presentation," because the baby's face will present itself before the rest of the head. A brow presentation occurs when the baby's head is in a position that is between a face presentation and a cephalic presentation. The brow presentation is also called the "military" presentation, as the baby appears to be imitating military personnel, standing at attention.

"The abnormality of the flexion attitude, or when the head is not flexed properly, is very rare – about one in every 500 births," Dr. Michael says. "If someone has a baby in a malpresentation position due to flexion attitude, the decision of the delivery will be left to the doctor. If the doctor feels that the baby is not too big and the pelvis is adequate, the woman can possibly have a vaginal delivery, although the risk for a C-section increases but will depend upon the view of the doctor."

"I wasn't aware of my daughter's malpresentation until right at delivery," says Kyle Looby, a homemaker and writer from Springfield, Ill. It was as she was crowning that the doctor slowed everything down and told me she was face-up – a face presentation. The doctor then told me to pant while he tried to turn her manually. Her malpresentation slowed down delivery considerably. My daughter came out with only a couple of bruises around her nose. The doctor told me that would go away within a few days. Other than that, she was perfect."

During pregnancy, babies will move, flip, kick and rotate quite often. It is not unusual for a baby to change position an average of four times during a normal pregnancy. Mothers who fear a malpresentation should discuss with their doctors what options are available. "Most babies will maintain whatever position they are in for the birthing process by 34 weeks," Dr. Michael says. "Expectant mothers can simply ask their doctor about any concerns they may have to ease their mind and have information as to what to expect. As malpresentations are still quite rare, it's safe to say that babies seem to know how to make their own grand entrance all on their own."