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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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What Is Cephalic Position?

The ideal fetal position for labor and delivery

• Why It's Best

Risks of Other Positions

• Determining Position
• Turning a Fetus

The cephalic position is when a fetus is head down when it is ready to enter the birth canal. This is one of a few variations of how a fetus can rest in the womb and is considered the ideal one for labor and delivery.

About 96% of babies are born in the cephalic position. Most settle into it between the 32nd and 36th weeks of pregnancy . Your healthcare provider will monitor the fetus's position during the last weeks of gestation to ensure this has happened by week 36.

If the fetus is not in the cephalic position at that point, the provider may try to turn it. If this doesn't work, some—but not all—practitioners will attempt to deliver vaginally, while others will recommend a Cesarean (C-section).

Getty Images

Why Is the Cephalic Position Best?

During labor, contractions dilate the cervix so the fetus has adequate room to come through the birth canal. The cephalic position is the easiest and safest way for the baby to pass through the birth canal.

If the fetus is in a noncephalic position, delivery becomes more challenging. Different fetal positions have a range of difficulties and varying risks.

A small percentage of babies present in noncephalic positions. This can pose risks both to the fetus and the mother, and make labor and delivery more challenging. It can also influence the way in which someone can deliver.

A fetus may actually find itself in any of these positions throughout pregnancy, as the move about the uterus. But as they grow, there will be less room to tumble around and they will settle into a final position.

It is at this point that noncephalic positions can pose significant risks.

Cephalic Posterior

A fetus may also present in an occiput or cephalic posterior position. This means they are positioned head down, but they are facing the abdomen instead of the back.

This position is also nicknamed "sunny-side up."

Presenting this way increases the chance of a painful and prolonged delivery.

There are three different types of breech fetal positioning:

• Frank breech: The legs are up with the feet near the head.
• Footling breech: One or both legs is lowered over the cervix.
• Complete breech: The fetus is bottom-first with knees bent.

A vaginal delivery is most times a safe way to deliver. But with breech positions, a vaginal delivery can be complicated.

When a baby is born in the breech position, the largest part—its head—is delivered last. This can result in them getting stuck in the birth canal (entrapped). This can cause injury or death.

The umbilical cord may also be damaged or slide down into the mouth of the womb, which can reduce or cut off the baby's oxygen supply.

Some providers are still comfortable performing a vaginal birth as long as the fetus is doing well. But breech is always a riskier delivery position compared with the cephalic position, and most cases require a C-section.

Likelihood of a Breech Baby

You are more likely to have a breech baby if you:

• Go into early labor before you're full term
• Have an abnormally shaped uterus, fibroids , or too much amniotic fluid
• Are pregnant with multiples
• Have placenta previa (when the placenta covers the cervix)

Transverse Lie

In transverse lie position, the fetus is presenting sideways across the uterus rather than vertically. They may be:

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

If a transverse lie is not corrected before labor, a C-section will be required. This is typically the case.

Determining Fetal Position

Your healthcare provider can determine if your baby is in cephalic presentation by performing a physical exam and ultrasound.

In the final weeks of pregnancy, your healthcare provider will feel your lower abdomen with their hands to assess the positioning of the baby. This includes where the head, back, and buttocks lie

If your healthcare provider senses that the fetus is in a breech position, they can use ultrasound to confirm their suspicion.

Turning a Fetus So They Are in Cephalic Position

External cephalic version (ECV) is a common, noninvasive procedure to turn a breech baby into cephalic position while it's still in the uterus.

This is only considered if a healthcare provider monitors presentation progress in the last trimester and notices that a fetus is maintaining a noncephalic position as your delivery date approaches.

External Cephalic Version (ECV)

ECV involves the healthcare provider applying pressure to your stomach to turn the fetus from the outside. They will attempt to rotate the head forward or backward and lift the buttocks in an upward position. Sometimes, they use ultrasound to help guide the process.

The best time to perform ECV is about 37 weeks of pregnancy. Afterward, the fetal heart rate will be monitored to make sure it’s within normal levels. You should be able to go home after having ECV done.

ECV has a 50% to 60% success rate. However, even if it does work, there is still a chance the fetus will return to the breech position before birth.

Natural Methods For Turning a Fetus

There are also natural methods that can help turn a fetus into cephalic position. There is no medical research that confirms their efficacy, however.

• Changing your position: Sometimes a fetus will move when you get into certain positions. Two specific movements that your provider may recommend include: Getting on your hands and knees and gently rocking back and forth. Another you could try is pushing your hips up in the air while laying on your back with your knees bent and feet flat on the floor (bridge pose).
• Playing stimulating sounds: Fetuses gravitate to sound. You may be successful at luring a fetus out of breech position by playing music or a recording of your voice near your lower abdomen.
• Chiropractic care: A chiropractor can try the Webster technique. This is a specific chiropractic analysis and adjustment which enables chiropractors to establish balance in the pregnant person's pelvis and reduce undue stress to the uterus and supporting ligaments.
• Acupuncture: This is a considerably safe way someone can try to turn a fetus. Some practitioners incorporate moxibustion—the burning of dried mugwort on certain areas of the body—because they believe it will enhance the chances of success.

A Word From Verywell

While most babies are born in cephalic position at delivery, this is not always the case. And while some fetuses can be turned, others may be more stubborn.

This may affect your labor and delivery wishes. Try to remember that having a healthy baby, and staying well yourself, are your ultimate priorities. That may mean diverting from your best laid plans.

Speaking to your healthcare provider about turning options and the safest route of delivery may help you adjust to this twist and feel better about how you will move ahead.

Glezerman M. Planned vaginal breech delivery: current status and the need to reconsider . Expert Rev Obstet Gynecol. 2012;7(2):159-166. doi:10.1586/eog.12.2

Cleveland Clinic. Fetal positions for birth .

MedlinePlus. Breech birth .

UT Southwestern Medical Center. Can you turn a breech baby around?

The American College of Obstetricians and Gynecologists. If your baby is breech .

Roecker CB. Breech repositioning unresponsive to Webster technique: coexistence of oligohydramnios .  Journal of Chiropractic Medicine . 2013;12(2):74-78. doi:10.1016/j.jcm.2013.06.003

By Cherie Berkley, MS Cherie Berkley is an award-winning journalist and multimedia storyteller covering health features for Verywell.

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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

Cephalic presentation

October 14, 2016

A cephalic presentation or head presentation or head-first presentation is a situation at childbirth where the fetus is in a longitudinal lie and the head enters the pelvis first; the most common form of cephalic presentation is the vertex presentation where the occiput is the leading part (the part that first enters the birth canal). All other presentations are abnormal (malpresentations) which are either more difficult to deliver or not deliverable by natural means.

The movement of the fetus to cephalic presentation is called head engagement. It occurs in the third trimester. In head engagement, the fetal head descends into the pelvic cavity so that only a small part (or none) of it can be felt abdominally. The perineum and cervix are further flattened and the head may be felt vaginally. Head engagement is known colloquially as the baby drop, and in natural medicine as the lightening because of the release of pressure on the upper abdomen and renewed ease in breathing. However, it severely reduces bladder capacity, increases pressure on the pelvic floor and the rectum, and the mother may experience the perpetual sensation that the fetus will “fall out” at any moment.

The vertex is the area of the vault bounded anteriorly by the anterior fontanelle and the coronal suture, posteriorly by the posterior fontanelle and the lambdoid suture and laterally by 2 lines passing through the parietal eminences.

In the vertex presentation the occiput typically is anterior and thus in an optimal position to negotiate the pelvic curve by extending the head. In an occiput posterior position, labor becomes prolonged and more operative interventions are deemed necessary. The prevalence of the persistent occiput posterior is given as 4.7 %

The vertex presentations are further classified according to the position of the occiput, it being right, left, or transverse, and anterior or posterior:

Left Occipito-Anterior (LOA), Left Occipito-Posterior (LOP), Left Occipito-Transverse (LOT); Right Occipito-Anterior (ROA), Right Occipito-Posterior (ROP), Right Occipito-Transverse (ROT);

By Mikael Häggström – Own work, Public Domain  

Cephalic presentation. (2016, September 17). In Wikipedia, The Free Encyclopedia . Retrieved 05:18, September 17, 2016, from https://en.wikipedia.org/w/index.php?title=Cephalic_presentation&oldid=739815165

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

, MD, Children's Hospital of Philadelphia

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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 Operative Vaginal Delivery Operative vaginal delivery involves application of forceps or a vacuum extractor to the fetal head to assist during the second stage of labor and facilitate delivery. Indications for forceps... read more , or cesarean delivery Cesarean Delivery Cesarean delivery is surgical delivery by incision into the uterus. The rate of cesarean delivery was 32% in the United States in 2021 (see March of Dimes: Delivery Method). The rate has fluctuated... read more .

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

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

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

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

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

Abnormal fetal lie, presentation, or position may occur with

Fetopelvic disproportion (fetus too large for the pelvic inlet)

Fetal congenital anomalies

Uterine structural abnormalities (eg, fibroids, synechiae)

Multiple gestation

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

Transverse lie

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

Breech presentation

There are several types of breech presentation.

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

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

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

Types of breech presentations

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

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

Predisposing factors for breech presentation include

Preterm labor Preterm Labor Labor (regular uterine contractions resulting in cervical change) that begins before 37 weeks gestation is considered preterm. Risk factors include prelabor rupture of membranes, uterine abnormalities... read more

Multiple gestation Multifetal Pregnancy Multifetal pregnancy is presence of > 1 fetus in the uterus. Multifetal (multiple) pregnancy occurs in up to 1 of 30 deliveries. Risk factors for multiple pregnancy include Ovarian stimulation... read more

Uterine abnormalities

Fetal anomalies

If delivery is vaginal, breech presentation may increase risk of

Umbilical cord prolapse

Perinatal death

It is best to detect abnormal fetal lie or presentation before delivery. During routine prenatal care, clinicians assess fetal lie and presentation with physical examination in the late third trimester. Ultrasonography can also be done. If breech presentation is detected, external cephalic version can sometimes move the fetus to vertex presentation before labor, usually at 37 or 38 weeks. This technique involves gently pressing on the maternal abdomen to reposition the fetus. A dose of a short-acting tocolytic ( terbutaline 0.25 mg subcutaneously) may help. The success rate is about 50 to 75%. For persistent abnormal lie or presentation, cesarean delivery is usually done at 39 weeks or when the woman presents in labor.

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 Operative Vaginal Delivery Operative vaginal delivery involves application of forceps or a vacuum extractor to the fetal head to assist during the second stage of labor and facilitate delivery. Indications for forceps... read more or cesarean delivery Cesarean Delivery Cesarean delivery is surgical delivery by incision into the uterus. The rate of cesarean delivery was 32% in the United States in 2021 (see March of Dimes: Delivery Method). The rate has fluctuated... read more 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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The ABCs of Cephalic Presentation: A Comprehensive Guide for Moms-to-Be

Updated on 24 November 2023

As expectant mothers eagerly anticipate the arrival of their little ones, understanding the intricacies of pregnancy becomes crucial. One term that frequently arises in discussions about childbirth is "cephalic presentation." In this article, we will understand its meaning, types, benefits associated with it, the likelihood of normal delivery and address common concerns expectant mothers might have.

What is the meaning of cephalic presentation in pregnancy?

Cephalic presentation means the baby's head is positioned down towards the birth canal, which is the ideal fetal position for childbirth. This position is considered optimal for a smoother and safer delivery. In medical terms, a baby in cephalic presentation is said to be in a "vertex" position.

The majority of babies naturally assume a cephalic presentation before birth. Other presentations, such as breech presentation (where the baby's buttocks or feet are positioned to enter the birth canal first) or transverse presentation (where the baby is lying sideways), may complicate the delivery process and may require medical intervention.

Cephalic presentation types

There are different types of cephalic presentation, each influencing the birthing process. The primary types include:

1. Vertex Presentation

The most common type where the baby's head is down, facing the mother's spine.

2. Brow Presentation

The baby's head is slightly extended, and the forehead presents first.

3. Face Presentation

The baby is positioned headfirst, but the face is the presenting part instead of the crown of the head.

Understanding these variations is essential for expectant mothers and healthcare providers to navigate potential challenges during labor.

You may also like: How to Get Baby in Right Position for Birth?

What are the benefits of cephalic presentation?

In order to understand whether cephalic presentation is good or bad, let’s take a look at its key advantages:

1. Easier Engagement

This presentation facilitates the baby's engagement in the pelvis, aiding in a smoother descent during labor.

2. Reduced Risk of Complications

Babies in head-first position typically experience fewer complications during delivery compared to other presentations.

3. Faster Labor Progression

This position is associated with quicker labor progression, leading to a potentially shorter and less stressful birthing process.

4. Lower Cesarean Section Rates

The chances of a cesarean section are significantly reduced when the baby is in cephalic presentation in pregnancy.

5. Optimal Fetal Oxygenation

The head-first position allows for optimal oxygenation of the baby as the head can easily pass through the birth canal, promoting a healthy start to life.

What are the chances of normal delivery in cephalic presentation?

The chances of a normal delivery are significantly higher when the baby is in cephalic or head-first presentation. Vaginal births are the natural outcome when the baby's head leads the way, aligning with the natural mechanics of childbirth.

While this presentation increases the chances of a normal delivery, it's important to note that individual factors, such as the mother's pelvic shape, the size of the baby, and the progress of labor, can also influence the delivery process. Sometimes complications may arise during labor and medical interventions or a cesarean section may be necessary.

You may also like: Normal Delivery Tips: An Expecting Mother's Guide to a Smooth Childbirth Experience

How to achieve cephalic presentation in pregnancy?

While fetal positioning is largely influenced by genetic and environmental factors, there are strategies to encourage head-first fetal position:

1. Regular Exercise

Engaging in exercises such as pelvic tilts and knee-chest exercises may help promote optimal fetal positioning.

2. Correct Posture

Maintaining good posture, particularly during the third trimester , can influence fetal positioning.

3. Hands and Knees Position

Spend some time on your hands and knees. This position may help the baby settle into the pelvis with the head down.

4. Forward-leaning Inversion

Under the guidance of a qualified professional, some women try forward-leaning inversions to encourage the baby to move into a head-down position. This involves positioning the body with the hips higher than the head.

5. Prenatal Yoga

Prenatal yoga focuses on strengthening the pelvic floor and promoting flexibility, potentially aiding in cephalic presentation.

6. Professional Guidance

Seeking guidance from a healthcare provider or a certified doula can provide personalized advice tailored to individual needs.

1. Cephalic presentation is good or bad?

Cephalic position is generally considered good as it aligns with the natural process of childbirth. It reduces the likelihood of complications and increases the chances of a successful vaginal delivery . However, it's essential to note that the overall health of both the mother and baby determines its appropriateness.

2. How to increase the chances of normal delivery in cephalic presentation?

Increasing the chances of normal delivery in cephalic presentation involves adopting healthy practices during pregnancy, such as maintaining good posture, engaging in appropriate exercises, and seeking professional guidance. However, individual circumstances vary, and consultation with a healthcare provider is paramount.

Final Thoughts

Navigating the journey of pregnancy involves understanding various aspects, and cephalic presentation plays a crucial role in determining the birthing experience. The benefits of a head-first position, coupled with strategies to encourage it, empower expectant mothers to actively participate in promoting optimal fetal positioning. As always, consulting with healthcare professionals ensures personalized care and guidance, fostering a positive and informed approach towards childbirth.

1. Makajeva J, Ashraf M. Delivery, Face and Brow Presentation. (2023). In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing

2. Boos R, Hendrik HJ, Schmidt W. (1987). Das fetale Lageverhalten in der zweiten Schwangerschaftshälfte bei Geburten aus Beckenendlage und Schädellage [Behavior of fetal position in the 2d half of pregnancy in labor with breech and vertex presentations]. Geburtshilfe Frauenheilkd

Anupama Chadha

Anupama Chadha, born and raised in Delhi is a content writer who has written extensively for industries such as HR, Healthcare, Finance, Retail and Tech.

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Medicine:Cephalic presentation

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A cephalic presentation or head presentation or head-first presentation is a situation at childbirth where the fetus is in a longitudinal lie and the head enters the pelvis first; the most common form of cephalic presentation is the vertex presentation, where the occiput is the leading part (the part that first enters the birth canal). [1] All other presentations are abnormal (malpresentations) and are either more difficult to deliver or not deliverable by natural means.

• 1 Engagement
• 2.1 Vertex presentation
• 2.2 Face presentation
• 2.3 Brow presentation
• 3 Reasons for predominance
• 4 Diagnosis
• 5 Management
• 6 References
• 7 External links

The movement of the fetus to cephalic presentation is called head engagement . It occurs in the third trimester. In head engagement, the fetal head descends into the pelvic cavity so that only a small part (or none) of it can be felt abdominally. The perineum and cervix are further flattened and the head may be felt vaginally. [2] Head engagement is known colloquially as the baby drop , and in natural medicine as the lightening because of the release of pressure on the upper abdomen and renewed ease in breathing. However, it severely reduces bladder capacity resulting in a need to void more frequently. [3]

Classification

In the vertex presentation the head is flexed and the occiput leads the way. This is the most common configuration and seen at term in 95% of singletons. [1] If the head is extended, the face becomes the leading part. Face presentations account for less than 1% of presentations at term. In the sinicipital presentation the large fontanelle is the presenting part; with further labor the head will either flex or extend more so that in the end this presentation leads to a vertex or face presentation. [1] In the brow presentation the head is slightly extended, but less than in the face presentation. The chin presentation is a variant of the face presentation with maximum extension of the head.

Non-cephalic presentations are the breech presentation (3.5%) and the shoulder presentation (0.5%). [1]

Vertex presentation

The vertex is the area of the vault bounded anteriorly by the anterior fontanelle and the coronal suture, posteriorly by the posterior fontanelle and the lambdoid suture and laterally by 2 lines passing through the parietal eminences.

In the vertex presentation the occiput typically is anterior and thus in an optimal position to negotiate the pelvic curve by extending the head. In an occiput posterior position, labor becomes prolonged, and more operative interventions are deemed necessary. [4] The prevalence of the persistent occiput posterior is given as 4.7%. [4]

The vertex presentations are further classified according to the position of the occiput , both right, left, or transverse and anterior or posterior:

• Left Occipito-Anterior (LOA), Left Occipito-Posterior (LOP), Left Occipito-Transverse (LOT)
• Right Occipito-Anterior (ROA), Right Occipito-Posterior (ROP), Right Occipito-Transverse (ROT)

The Occipito-Anterior position is ideal for birth; it means that the baby is lined up so as to fit through the pelvis as easily as possible. The baby is head down, facing the spine, with its back anterior. In this position, the baby's chin is tucked onto its chest, so that the smallest part of its head will be applied to the cervix first. The position is usually "Left Occiput Anterior", or LOA. Occasionally, the baby may be "Right Occiput Anterior", or ROA. [5]

Face presentation

Factors that predispose to face presentation are prematurity, macrosomia, anencephaly and other malformations, cephalopelvic disproportion, and polyhydramnios. [6] [7] In an uncomplicated face presentation duration of labor is not altered. Perinatal losses with face presentation occur with traumatic version and extraction and midforceps procedures [7] Duff indicates that the prevalence of face presentations is about 1/500–600, [7] while Benedetti et al. found it to be 1/1,250 term deliveries. [8]

Face presentations are classified according to the position of the chin (mentum):

• Left Mento-Anterior (LMA), Left Mento-Posterior (LMP), Left Mento-Transverse (LMT)
• Right Mento-Anterior (RMA), Right Mento-Posterior (RMP), Right Mento-Transverse (RMT)

Brow presentation

While some consider the brow presentation as an intermediate stage towards the face presentation, [1] others disagree. Thus Bhal et al. indicated that both conditions are about equally common (1/994 face and 1/755 brow positions), and that prematurity was more common with face while postmaturity was more common with brow positions. [9]

Reasons for predominance

The piriform ( pear -shaped) morphology of the uterus has been given as the major cause for the finding that most singletons favor the cephalic presentation at term. [1] The fundus is larger and thus a fetus will adapt its position so that the bulkier and more movable podalic pole makes use of it, while the head moves to the opposite site. Factors that influence this positioning include the gestational age (earlier in gestation breech presentations are more common as the head is relatively bigger), size of the head, malformations, amount of amniotic fluid , presence of multiple gestations, presence of tumors, and others.

Two-thirds of all vertex presentations are LOA, possibly because of the asymmetry created by the descending colon that is on the left side of the pelvis [ citation needed ] .

Usually performing the Leopold maneuvers will demonstrate the presentation and possibly the position of the fetus. [10] Ultrasound examination delivers the precise diagnosis and may indicate possible causes of a malpresentation. On vaginal examination, the leading part of the fetus becomes identifiable after the amniotic sac has been broken and the head is descending in the pelvis.

Many factors determine the optimal way to deliver a baby. A vertex presentation is the ideal situation for a vaginal birth, although occiput posterior positions tend to proceed more slowly, often requiring intervention in the form of forceps , vacuum extraction, or caesarean section . [4] In a large study, a majority of brow presentations were delivered by caesarean section, however, because of 'postmaturity', factors other than labour dynamics may have played a role. [9] Most face presentations can be delivered vaginally as long as the chin is anterior; there is no increase in fetal or maternal mortality. [11] Mento-posterior positions cannot be delivered vaginally in most cases (unless rotated) and are candidates for caesarean section in contemporary management. [11]

• ↑ 1.0 1.1 1.2 1.3 1.4 1.5 Williams Obstetrics, 14th edition. . Appleton-Century-Crofts (1971) Library of Congress Catalogue Card Number 73-133179. pp. 322–2.  
• ↑ "Starting labour" . pregnancy-bliss.co.uk . http://www.pregnancy-bliss.co.uk/headengagement.html .  
• ↑ "Lightening During Pregnancy as an Early Sign of Labor" . Giving Birth Naturally . http://www.givingbirthnaturally.com/lightening-during-pregnancy.html .  
• ↑ 4.0 4.1 4.2 "Persitent occiput posterior presentation — a clinical problem". Acta Obstet Gynecol Scand 198 (4): 117–9. 1994. PMID   7975796 .  
• ↑ "Optimum Foetal Positioning" . Homebirth.org . http://www.homebirth.org.uk/ofp.htm .  
• ↑ "Face and brow presentation: independent risk factors.". J Matern Fetal Neonatal Med 21 (6): 357–60. 2008. doi : 10.1080/14767050802037647 . PMID   18570114 .  
• ↑ 7.0 7.1 7.2 Duff, P (1981). "Diagnosis and Management of Face Presentation". Obstet Gynecol 57 (1): 105–12. PMID   7005774 .  
• ↑ "Face Presentation at Term". Obstet Gynecol 55 (2): 199–202. 1980. PMID   7352081 .  
• ↑ 9.0 9.1 "A population study of face and brow presentation". J Obstet Gynaecol 18 (3): 231–5. 1998. doi : 10.1080/01443619867371 . PMID   15512065 .  
• ↑ "Accuracy of Leopold Maneuvrers in Screening for Malpresentation: A Prospective Study". Birth 20 (3): 132–5. September 1993. doi : 10.1111/j.1523-536X.1993.tb00437.x . PMID   8240620 .  
• ↑ 11.0 11.1 "Face presentation: retrospective study of 32 cases at term". Gynecol Obstet Fertil 34 (5): 393–6. 2006. doi : 10.1016/j.gyobfe.2005.07.042 . PMID   16630740 .  

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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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How your twins’ fetal positions affect labor and delivery

Twin fetal presentation – also known as the position of your babies in the womb – dictates whether you'll have a vaginal or c-section birth. Toward the end of pregnancy, most twins will move in the head-down position (vertex), but there's a risk that the second twin will change position after the first twin is born. While there are options to change the second twin's position, this can increase the risk of c-section and other health issues. Learn about the six possible twin fetal presentations: vertex-vertex, vertex-breech, breech-breech, vertex-transverse, breech-transverse, and transverse-transverse – and how they'll impact your delivery and risks for complications.

What is fetal presentation and what does it mean for your twins?

As your due date approaches, you might be wondering how your twins are currently positioned in the womb, also known as the fetal presentation, and what that means for your delivery. Throughout your pregnancy, your twin babies will move in the uterus, but sometime during the third trimester – usually between 32 and 36 weeks – their fetal presentation changes as they prepare to go down the birth canal.

The good news is that at most twin births, both babies are head-down (vertex), which means you can have a vaginal delivery. In fact, nearly 40 percent of twins are delivered vaginally.

But if one baby has feet or bottom first (breech) or is sideways (transverse), your doctor might deliver the lower twin vaginally and then try to rotate the other twin so that they face head-down (also called external cephalic version or internal podalic version) and can be delivered vaginally. But if that doesn't work, there's still a chance that your doctor will be able to deliver the second twin feet first vaginally via breech extraction (delivering the breech baby feet or butt first through the vagina).

That said, a breech extraction depends on a variety of factors – including how experienced your doctor is in the procedure and how much the second twin weighs. Studies show that the higher rate of vaginal births among nonvertex second twins is associated with labor induction and more experienced doctors, suggesting that proper delivery planning may increase your chances of a vaginal birth .

That said, you shouldn't totally rule out a Cesarean delivery with twins . If the first twin is breech or neither of the twins are head-down, then you'll most likely have a Cesarean delivery.

Research also shows that twin babies who are born at less than 34 weeks and have moms with multiple children are associated with intrapartum presentation change (when the fetal presentation of the second twin changes from head-down to feet first after the delivery of the first twin) of the second twin. Women who have intrapartum presentation change are more likely to undergo a Cesarean delivery for their second twin.

Here's a breakdown of the different fetal presentations for twin births and how they will affect your delivery.

Head down, head down (vertex, vertex)

This fetal presentation is the most promising for a vaginal delivery because both twins are head-down. Twins can change positions, but if they're head-down at 28 weeks, they're likely to stay that way.

When delivering twins vaginally, there is a risk that the second twin will change position after the delivery of the first. Research shows that second twins change positions in 20 percent of planned vaginal deliveries. If this happens, your doctor may try to rotate the second twin so it faces head-down or consider a breech extraction. But if neither of these work or are an option, then a Cesarean delivery is likely.

In vertex-vertex pairs, the rate of Cesarean delivery for the second twin after a vaginal delivery of the first one is 16.9 percent.

Like all vaginal deliveries, there's also a chance you'll have an assisted birth, where forceps or a vacuum are needed to help deliver your twins.

Head down, bottom down (vertex, breech)

When the first twin's (the lower one) head is down, but the second twin isn't, your doctor may attempt a vaginal delivery by changing the baby's position or doing breech extraction, which isn't possible if the second twin weighs much more than the first twin.

The rates of emergency C-section deliveries for the second twin after a vaginal delivery of the first twin are higher in second twins who have a very low birth weight. Small babies may not tolerate labor as well.

Head down, sideways (vertex, transverse)

If one twin is lying sideways or diagonally (oblique), there's a chance the baby may shift position as your labor progresses, or your doctor may try to turn the baby head-down via external cephalic version or internal podalic version (changing position in the uterus), which means you may be able to deliver both vaginally.

Bottom down, bottom down (breech, breech)

When both twins are breech, a planned C-section is recommended because your doctor isn't able to turn the fetuses. Studies also show that there are fewer negative neonatal outcomes for planned C-sections than planned vaginal births in breech babies.

As with any C-section, the risks for a planned one with twins include infection, loss of blood, blood clots, injury to the bowel or bladder, a weak uterine wall, placenta abnormalities in future pregnancies and fetal injury.

Bottom down, sideways (breech, transverse)

When the twin lowest in your uterus is breech or transverse (which happens in 25 percent of cases), you'll need to have a c-section.

Sideways, sideways (transverse, transverse)

This fetal presentation is rare with less than 1 percent of cases. If both babies are lying horizontally, you'll almost definitely have a C-section.

Learn more:

• Twin fetal development month by month
• Your likelihood of having twins or more
• When and how to find out if you’re carrying twins or more

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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 .

Cleveland Clinic. Fetal Positions for Birth: https://my.clevelandclinic.org/health/articles/9677-fetal-positions-for-birth Opens a new window [Accessed July 2021]

Mayo Clinic. Fetal Presentation Before Birth: https://www.mayoclinic.org/healthy-lifestyle/pregnancy-week-by-week/multimedia/fetal-positions/sls-20076615?s=7 Opens a new window [Accessed July 2021]

NHS. Giving Birth to Twins or More: https://pubmed.ncbi.nlm.nih.gov/29016498/ Opens a new window [Accessed July 2021]

Science Direct. Breech Extraction: https://www.sciencedirect.com/topics/medicine-and-dentistry/breech-extraction Opens a new window [Accessed July 2021]

Obstetrics & Gynecology. Clinical Factors Associated With Presentation Change of the Second Twin After Vaginal Delivery of the First Twin https://pubmed.ncbi.nlm.nih.gov/29016498/ Opens a new window [Accessed July 2021]

American Journal of Obstetrics and Gynecology. Fetal presentation and successful twin vaginal delivery: https://www.ajog.org/article/S0002-9378(04)00482-X/fulltext [Accessed July 2021]

The Journal of Maternal-Fetal & Neonatal Medicine. Changes in fetal presentation in twin pregnancies https://www.tandfonline.com/doi/abs/10.1080/14767050400028592 Opens a new window [Accessed July 2021]

Reviews in Obstetrics & Gynecology. An Evidence-Based Approach to Determining Route of Delivery for Twin Gestations https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3252881/ Opens a new window [Accessed July 2021]

Nature. Neonatal mortality and morbidity in vertex–vertex second twins according to mode of delivery and birth weight: https://www.nature.com/articles/7211408 Opens a new window [Accessed July 2021]

Cochrane. Planned cesarean for a twin pregnancy: https://www.cochrane.org/CD006553/PREG_planned-caesarean-section-twin-pregnancy Opens a new window [Accessed July 2021]

Kids Health. What Is the Apgar Score?: https://www.kidshealth.org/Nemours/en/parents/apgar0.html Opens a new window [Accessed July 2021]

American Journal of Obstetrics & Gynecology. Neonatal mortality in second twin according to cause of death, gestational age, and mode of delivery https://pubmed.ncbi.nlm.nih.gov/15467540/ Opens a new window [Accessed July 2021]

Lancet. Planned cesarean section versus planned vaginal birth for breech presentation at term: a randomised multicentre trial. Term Breech Trial Collaborative Group https://pubmed.ncbi.nlm.nih.gov/11052579/ Opens a new window [Accessed July 2021]

Cleveland Clinic. Cesarean Birth (C-Section): https://my.clevelandclinic.org/health/treatments/7246-cesarean-birth-c-section Opens a new window [Accessed July 2021]

St. Jude Medical Staff. Delivery of Twin Gestation: http://www.sjmedstaff.org/documents/Delivery-of-twins.pdf Opens a new window [Accessed July 2021]

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External Cephalic Version—A Chance for Vaginal Delivery at Breech Presentation

Ionut marcel cobec.

1 Clinic of Obstetrics and Gynecology, Diakoneo Diak Klinikum Schwäbisch Hall, Diakoniestrasse 10, 74523 Schwäbisch Hall, Germany

Vlad Bogdan Varzaru

Tamas kövendy, lorant kuban, anca-elena eftenoiu.

2 Clinic of Internal Medicine, Hohenloher Krankenhaus Öhringen, 74613 Öhringen, Germany

Aurica Elisabeta Moatar

Andreas rempen.

Background and Objectives : In recent years, the rate of caesarean section (CS) has increased constantly. Although vaginal breech delivery has a long history, breech presentation has become the third most common indication for CS. This study aims to identify factors associated with the success of external cephalic version (ECV), underline the success rate of ECV for breech presentation and highlight the high rate of vaginal delivery after successful ECV. Material and Methods : This retrospective observational study included 113 patients with singleton fetuses in breech presentation, who underwent ECV from January 2016 to March 2021 in the Clinic of Obstetrics and Gynecology, Diakonieklinikum Schwäbisch Hall, Germany. Maternal and fetal parameters and data related to procedure and delivery were collected. Possible predictors of successful ECV were evaluated. Results : The success rate of ECV was 54.9%. The overall rate of vaginal birth was 44.2%, regardless of ECV outcome. The vaginal birth rate after successful ECV was 80.6%. Overall, 79.0% of women with successful ECV delivered spontaneously without complications, 19.4% delivered through CS performed during labor by medical necessity, and 1.6% delivered through vacuum extraction. ECV was performed successfully in three of the four women with history of CS. Gravidity, parity, maternal age, gestational age, fetal weight, and amniotic fluid index (AFI) were significantly correlated with the outcome of ECV. Conclusions : ECV for breech presentation is a safe procedure with a good success rate, thus increasing the proportion of vaginal births. Maternal and fetal parameters can be used to estimate the chances of successful ECV.

1. Introduction

In recent years, the rate of caesarean section (CS) has increased constantly in Germany [ 1 ]. In singleton pregnancies, an important indication of CS has been fetal malpresentation. In clinical practice, breech presentation (praesentation caudae) is the most common abnormal fetal presentation, which refers to fetuses lying bottom- or feet/knee-first rather than head-first [ 2 ]. Breech presentation is defined as a longitudinal positioning of the fetus with the buttocks or feet closest to the cervix. In Germany, fetal breech presentation at term occurs in about 3% of singleton pregnancies. The rate of breech presentation decreases with gestational age. This rate is about 9% between 33 and 36 pregnancy weeks, 18% between 28 and 32 weeks, and about 30% before the 28th pregnancy week [ 3 ].

The predisposing factors for breech presentation are uterine anomalies (e.g., uterus arcuatus, uterus bicornis, uterus duplex), uterus myomatosus, pelvic tumor, advanced multiparity, history of cesarean delivery or breech delivery, gestational diabetes, multiple gestation, congenital anomalies of the fetus (neural tube defects, fetal hydrocephalus or anencephaly), neuromuscular diseases, cephalo-pelvic disproportion, prematurity, low fetal birth weight, oligohydramnios, short umbilical cord, polar placentation, and placenta praevia [ 4 , 5 ]. However, in about 75% of cases, no specific cause of term breech presentation could be identified [ 4 , 6 ]. The main types of breech presentation are frank (≈60–70%), complete (≈4–10%), and incomplete breech (≈20–36%) [ 7 , 8 ].

Vaginal breech delivery has a long history. Studies have shown that perinatal and neonatal mortality rates, as well as serious neonatal morbidity rates, were higher in the planned vaginal delivery than in the planned cesarean delivery at breech presentation [ 9 ]. These findings significantly lead to CS being accepted by obstetricians as the safer option for breech delivery [ 9 ].

In the United States, there has been an increase in the frequency of CS in the past 20 years. One in three women giving birth in the USA will undergo a CS [ 10 ]. In many other developed and developing countries, this rate is the same. For example, in Korea, the frequency of CS was about 36.9% in 2012, CS being the usual method of delivery for term breech presentation [ 11 ]. Breech presentation became the third most common indication for CS, after previous CS and labor dystocia [ 12 ].

The maternal morbidity of CS is approximately three times higher than that of vaginal delivery [ 13 ]. The maternal risks of CS compared to vaginal delivery are well known. These include greater blood loss, thrombotic events, unplanned hysterectomy, operative damage to other organs, mortality, longer hospital stay with higher costs, and more readmissions than patients undergoing vaginal delivery [ 14 ]. Additional maternal complications of CS include scarring, chronic pain, and intestinal obstruction caused by adhesive disease. Moreover, in the following pregnancies, a previous cesarean delivery may cause a higher rate of placental abnormalities, unexplained stillbirth, as well as repeated surgical delivery in many cases [ 14 ]. However, vaginal delivery could also have maternal complications compared to CS, such as postpartum urinary incontinence and pelvic organ prolapse [ 15 ].

In case of fetal breech position, the external cephalic version (ECV) could be an option for reducing the number of CSs and vaginal breech deliveries [ 9 ]. ECV is a technique used to convert the fetal breech presentation into a cephalic position with targeted manual pressure on the mother’s abdominal wall at-term or near-term pregnancies in order to increase the chance of a vaginal cephalic birth [ 9 , 16 , 17 ]. ECV can be carried out with or without analgesics and with or without tocolytic therapy [ 18 ].

Factors favoring the success of ECV could be multiparous women, non-anterior placental location, palpability of the fetal skull, lower maternal body mass index, the type of breech presentation (for example, the frank breech presentation is associated with lower rates of success) and, of course, the experience of the physician in performing ECV [ 10 , 18 , 19 ]. Placental abruption, vaginal bleeding, fetal injury (including fractures and brachial plexus injuries), and pathological cardiotocography (CTG) findings, such as fetal bradycardia, may represent complications of the method [ 20 ].

The aim of this study is to identify factors associated with the success of ECV, highlight the relevance and success rate of ECV for breech presentation, and underline the high rate of vaginal deliveries in patients with successful ECV for breech presentation.

2. Material and Methods

This study represents a retrospective and anonymized data analysis over a period of 5 years. We reviewed the records of 113 women who underwent ECV from January 2016 to March 2021 in the Clinic of Obstetrics and Gynecology, Diakoneo Diak Klinikum Schwäbisch Hall, Germany. In our study, we included all patients with singleton fetuses in breech presentation who agreed to the maneuver. The ECV was performed by different senior consultants. Prior to ECV, an ultrasound control was performed, and the possible risks of the maneuver were discussed. Each patient signed the ECV informed consent. ECV was not performed if the patient rejected ECV or if there were absolute contraindications of ECV.

For 30 min before and during the ECV, the patient received an infusion with tocolysis with fenoterol. Before and after the ECV, a CTG control was performed. The ECV was attempted under ultrasound control of the fetal heartbeat. Fetal biometric parameters were obtained sonographically. The patient was placed in a comfortable lying position with knees slightly elevated. The patient was allowed to end the maneuver at any point in time.

Maternal age, number of pregnancies, number of childbirths, history of CS, ultrasonographic findings (type of breech presentation, placental location, amniotic fluid index), characteristics of ECV (gestational age at ECV, fetal weight at ECV, success of ECV, direction in which successful ECV was performed, complications during and after ECV), and birth-related characteristics (planned and real type of delivery, gestational age at birth, fetal weight at birth) were collected from our database. Data were analyzed using IBM SPSS Statistics 20. Grouping by the dichotomous outcome of ECV, we used either χ 2 analysis or Fisher’s exact test for categorical variables and independent samples t -test for continuous variables. Multiple binary logistic regression was used to identify possible predictors of the outcome of ECV. We used the significance threshold of α = 0.05 corresponding to the 95% confidence interval.

In the observed five years, we registered 6619 singleton deliveries out of a total of 6825 deliveries and a general CS rate of 24.9%. Overall, 11.0% were elective CSs and 13.9% CSs were performed during labor by medical necessity. In total, 4.8% of all registered deliveries in our clinic in the observed period were CSs with breech presentation. In our sample of 113 women, the mean maternal age was 31.69 years ( SD = 4.44)—the youngest patient was 18 years old and the oldest patient was 43 years old. In total, 53.1% of the women were primigravida and 61.9% were nullipara. Four (3.5%) women had a history of CS.

Before ECV was performed, the fetal back faced the maternal left in 60 (53.1%) cases and the maternal right in 53 (46.9%) cases. In 56 (49.6%) cases, the placenta was located on the posterior wall, in 47 (41.6%) on the anterior wall, in 6 (5.3%) in the fundus, and in 4 (3.6%) on the left or right wall. The mean amniotic fluid index (AFI) at ECV was 14.88 ( SD = 3.58), ranging from 8 to 25. The mean gestational age at ECV was 261.82 days ( SD = 4.98). The minimum gestational age at ECV in our cohort was 35 + 2 weeks of pregnancy and the latest performed ECV was at 40 + 0 weeks of pregnancy. In 12 cases (10.6%), ECV was performed under 37 weeks of gestation because of medical necessity and with informed patient consent. The mean fetal weight at ECV was 2966.02 g ( SD = 391.06), ranging from 2158 g to 4123 g.

The success rate of ECV was 54.9%. ECV succeeded backwards in 39 (62.9%) cases and forwards in 23 (37.1%) cases. Overall, 101 (89.4%) of the ECVs were performed without any complications during the maneuver. In total, 12 (10.6%) cases encountered complications during the attempt of ECV. The complications were represented by fetal bradycardia with quick recovery in 7 cases, maternal intolerable abdominal pain in 2 cases, vena cava compression with quick recovery in 1 case, low maternal tocolysis tolerance in 1 case, and maternal nausea and emesis in 1 case. A single patient (0.9%) developed contractions during post-ECV monitoring, while 112 patients (99.1%) had no complications post-ECV.

The overall rate of vaginal birth was 44.2%, regardless of ECV outcome. The successful ECV group was planned for spontaneous delivery. The vaginal birth rate of the successful ECV group was 80.6%. Out of 62 patients, 49 (79.0%) delivered spontaneously without complications, 12 (19.4%) delivered through CS performed during labor by medical necessity, and 1 (1.6%) delivered through vacuum extraction. ECV was performed successfully in three of the four women with history of CS; three delivered through CS and one delivered vaginally. The unsuccessful ECV group delivered through CS.

For gestational age and fetal weight at birth, eight observations were excluded from the analysis due to missing values. Five patients were planned for CS and decided to deliver in another clinic, while three patients were planned for spontaneous delivery and decided upon home birth. The mean gestational age at birth was 275.41 days ( SD = 8.96), the earliest delivery was at 37 + 0 weeks of pregnancy and the latest was at 42 + 0 weeks of pregnancy. The mean fetal weight at birth was 3350.43 ( SD = 470.69), ranging from 2180 g to 4470 g.

We analyzed the relationship between the outcome of ECV and the following categorical variables: gravidity, parity, history of CS, fetal back position before ECV and placental location ( Table 1 ). Multigravidity, defined as having been pregnant more than once, and a parity ≥ 1 were significantly associated with a successful ECV.

Association between outcome ECV and gravidity, parity, history of CS, fetal back position before ECV and placental location.

We compared maternal age, gestational age, fetal weight and AFI at ECV for successful and unsuccessful ECV using an independent samples t -test and found significant differences ( Table 2 ). For gestational age, we conducted a Welch’s t -test since equal variances could not be assumed. The other continuous variables were compared using Student’s t -test.

Comparison between maternal age, gestational age at ECV, fetal weight at ECV and AFI at ECV for successful and unsuccessful ECV using independent samples t -test.

Multiple logistic regression analysis was used to construct a prediction model for the outcome of ECV and covariates parity, maternal age, gestational age at ECV, fetal weight at ECV and AFI at ECV ( Table 3 ). A parity ≥ 1 and a higher maternal age were found to be favorable predictors of successful ECV in our prediction model.

Results of multiple logistic regression analysis for predictors of successful ECV.

4. Discussions

This study was performed in a clinic where the CS rate is lower than the reported CS rate for Germany, which is about 31.8% according to the official statistics [ 3 ]. In 2000, a large international multicenter randomized clinical trial, called the Term Breech Trial, compared vaginal deliveries with planned cesarean deliveries [ 21 ]. It was shown that perinatal and neonatal mortality rates, as well as serious neonatal morbidity rates, were significantly higher in the planned vaginal delivery group than in the planned cesarean delivery group (16% vs. 5%) at breech presentation. These findings significantly led to obstetricians choosing CS as the safer option for breech delivery in the 2000s [ 9 ]. For this reason, more than 12% of the CSs in Germany are performed in case of breech presentation. For example, in the west-central part of Germany, in the State of Hessen, about 90% of breech fetuses at term are delivered via CS [ 3 ]. In our clinic, CS at breech presentation represented 4.8% of all registered deliveries from 2016 to 2020.

In case of fetal breech position, ECV could be a successful and safe option to reduce the number of CSs [ 22 , 23 ]. The routine use of ECV could lower the rate of surgical delivery in case of breech presentation by approximately two-thirds in term pregnancies [ 9 ]. In most cases, fenoterol is used as tocolytic therapy, mainly as a continuous tocolysis. The improvement of the monitoring during the ECV with sonography and CTG and the use of tocolytic therapy made this method safer, thus reducing the complication rate associated with ECV [ 18 ].

By performing ECV, we aim to increase the proportion of vaginal cephalic delivery and thereby decrease the rate of CSs. For these reasons, ECV can be considered the first-line management in dealing with uncomplicated breech presentation at term. The method is recommended by Cochrane and the American and Royal Colleges of Obstetrics and Gynecologists, as well as by the German Society for Gynecology and Obstetrics (Deutsche Gesellschaft für Gynäkologie und Geburtshilfe) [ 3 , 24 , 25 ].

ECV would be generally recommended after 37 weeks of gestation [ 9 , 16 ]. It is performed as an elective procedure in non-laboring women, aiming to improve the chance of vaginal cephalic birth. Attempting ECV before term, between 34th and 36th pregnancy weeks, can be associated with an increase in late preterm birth [ 17 ]. According to the German guidelines, ECV should be offered to all women with uncomplicated breech presentation by singleton pregnancies in hospitals where facilities for an emergency CS are present [ 3 , 20 ]. In a study performed by Weiniger et al., the CS rate among women with successful ECV was 20.2%, whereas among women with persistent breech presentation at delivery it was 94.9% [ 26 ]. We registered a CS rate for successful ECV of 19.4%, while the unsuccessful ECV patients delivered through CS.

Furthermore, women who underwent vaginal delivery after a successful ECV had lower odds of developing endometriosis and sepsis and shorter hospitalization, therefore lower hospital charges [ 26 ]. In contrast, these women could have a higher risk of chorioamnionitis. Attempted ECV may be also associated with an increased risk of a low APGAR score at 5 min [ 6 ]. According to the literature, the absolute risk of all complications of ECV is approximately 1% in fetuses at term [ 14 ]. We noticed in our study that the registered complications were minimal and insignificant compared to the high rate of successful ECV, followed by a high rate of vaginal deliveries.

Women with singleton pregnancy and breech presented fetus without the following pathologies are potentially eligible for ECV near term (≥36 weeks). These pathologies include multiple gestation, onset of active labor, rupture of membranes, oligohydramnios, antepartum hemorrhage or history with placental abruption, pelvic abnormalities, severe preeclampsia or eclampsia, pathological Doppler or CTG, placenta praevia, placenta accreta, and infant with major congenital anomalies or growth restrictions [ 2 ].A point system, such as Kainer score, can be helpful to estimate the success rate of ECV, which includes parameters, such as AFI, placental location, fetal position, nuchal cord, estimated fetal weight, parity, fetal engagement, and uterine tone [ 27 , 28 ]. We noticed positive results even though we did not apply this score.

Multiparous women are known to have higher ECV success rates [ 9 ]. Our study shows that multigravidity and a parity ≥ 1 are associated with successful ECV. The absence of nulliparity was also identified as an important predictor of successful ECV, which supports the findings of previous studies.

According to the literature, ECV is considered safe in women with a history of CS and some studies showed that the success rate of ECV is comparable to that of women with no previous CS [ 29 , 30 , 31 , 32 ]. Although rare, we registered four cases with a history of CS. ECV was successful in three of them, but only one delivered vaginally. In our sample, the fetal back faced either the maternal left or right. We found no statistically significant relationship between the fetal position and the outcome of the maneuver.

The anterior placental location has been reported as being associated with a lower rate of success, probably due to the anterior location of the placenta making it difficult to perform ECV [ 9 ]. In the present study, we included patients with anterior, posterior, lateral, and fundal placental location. We noticed that the relationship between placental location and ECV outcome was not significant.

Our study included women between 18 and 43 years old. The group with successful ECV had a higher mean maternal age than the group with unsuccessful ECV, therefore we included maternal age in our logistic regression analysis. In our prediction model, higher maternal age was found to be a predictor for successful ECV, therefore the success rate increases with maternal age. Other studies did report similar results [ 33 , 34 ]. It is important to note that there may be other related variables affecting this relationship, for example, BMI, which we did not take into account. According to the literature, high BMI values are associated with a low success rate of ECV and a decrease in the rate of vaginal delivery after successful ECV [ 35 ].

The relationship between estimated fetal weight at ECV and ECV outcome is controversial [ 9 , 34 ]. We found an association between the success of the maneuver and higher fetal weight, as well as higher gestational age at ECV. An explanation could be that a larger fetus, which corresponds to a higher gestational age, is more palpable [ 27 , 36 ].

It has been reported that a higher AFI is associated with successful ECV [ 18 , 37 , 38 ]. In the present study, the group with successful ECV had a higher mean AFI than the group with unsuccessful ECV. It is important to note that the minimum AFI score registered was eight.

The safety, efficacy, and cost-effectiveness of ECV for breech presentation followed by vaginal delivery are underlined in our study through good clinical practice and are sustained by other performed studies [ 2 ].

5. Conclusions

ECV for breech presentation is a safe procedure with a good success rate which increases the proportion of vaginal births. Maternal and fetal parameters can be used to estimate the chances of successful ECV. Multigravidity, absence of nulliparity, higher maternal age, higher gestational age, higher fetal weight, and higher AFI are all associated with successful ECV.

Funding Statement

This research received no external funding.

Author Contributions

I.M.C. and A.R. conceived and planned in detail the present study. I.M.C., V.B.V. and T.K. extracted and analyzed the entire patient data. A.-E.E. performed the computations and interpreted the patient data together with I.M.C., L.K., V.B.V. and A.E.M., I.M.C. took the lead in writing the manuscript with input from T.K., V.B.V., A.-E.E. and A.E.M., in consultation with A.R., I.M.C. and A.R. supervised this study. All authors discussed the results and commented on the manuscript. All authors have read and agreed to the published version of the manuscript.

Institutional Review Board Statement

This study used pre-existing, anonymized and irreversibly de-identified data. Approval from the ethics committee was not required.

Informed Consent Statement

This retrospective study used pre-existing, anonymized and irreversibly de-identified data.

Conflicts of Interest

The authors declare no conflict of interest.

Publisher’s Note: MDPI stays neutral with regard to jurisdictional claims in published maps and institutional affiliations.

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F.A.A. Audit of Boeing’s 737 Max Production Found Dozens of Issues

The company failed 33 of 89 audits during an examination conducted by the Federal Aviation Administration after a panel blew off an Alaska Airlines jet in January.

By Mark Walker

Reporting from Washington

A six-week audit by the Federal Aviation Administration of Boeing’s production of the 737 Max jet found dozens of problems throughout the manufacturing process at the plane maker and one of its key suppliers, according to a slide presentation reviewed by The New York Times.

The air-safety regulator initiated the examination after a door panel blew off a 737 Max 9 during an Alaska Airlines flight in early January. Last week, the agency announced that the audit had found “multiple instances” in which Boeing and the supplier, Spirit AeroSystems, failed to comply with quality-control requirements, though it did not provide specifics about the findings.

The presentation reviewed by The Times, though highly technical, offers a more detailed picture of what the audit turned up. Since the Alaska Airlines episode, Boeing has come under intense scrutiny over its quality-control practices, and the findings add to the body of evidence about manufacturing lapses at the company.

For the portion of the examination focused on Boeing, the F.A.A. conducted 89 product audits, a type of review that looks at aspects of the production process. The plane maker passed 56 of the audits and failed 33 of them, with a total of 97 instances of alleged noncompliance, according to the presentation.

The F.A.A. also conducted 13 product audits for the part of the inquiry that focused on Spirit AeroSystems, which makes the fuselage, or body, of the 737 Max. Six of those audits resulted in passing grades, and seven resulted in failing ones, the presentation said.

At one point during the examination, the air-safety agency observed mechanics at Spirit using a hotel key card to check a door seal, according to a document that describes some of the findings. That action was “not identified/documented/called-out in the production order,” the document said.

In another instance, the F.A.A. saw Spirit mechanics apply liquid Dawn soap to a door seal “as lubricant in the fit-up process,” according to the document. The door seal was then cleaned with a wet cheesecloth, the document said, noting that instructions were “vague and unclear on what specifications/actions are to be followed or recorded by the mechanic.”

Asked about the appropriateness of using a hotel key card or Dawn soap in those situations, a spokesman for Spirit, Joe Buccino, said the company was “reviewing all identified nonconformities for corrective action.”

Jessica Kowal, a spokeswoman for Boeing, said the plane maker was continuing “to implement immediate changes and develop a comprehensive action plan to strengthen safety and quality, and build the confidence of our customers and their passengers.”

In late February, the F.A.A. gave the company 90 days to develop a plan for quality-control improvements. In response, its chief executive, Dave Calhoun, said that “we have a clear picture of what needs to be done,” citing in part the audit findings.

Boeing said this month that it was in talks to acquire Spirit , which it spun out in 2005. Mr. Buccino said on Monday that Spirit had received preliminary audit findings from the F.A.A. and planned to work with Boeing to address what the regulator had raised. He said Spirit’s goal was to reduce to zero the number of defects and errors in its processes.

“Meanwhile, we continue multiple efforts undertaken to improve our safety and quality programs,” Mr. Buccino said. “These improvements focus on human factors and other steps to minimize nonconformities.”

The F.A.A. said it could not release specifics about the audit because of its active investigation into Boeing in response to the Alaska Airlines episode. In addition to that inquiry, the National Transportation Safety Board is investigating what caused the door panel to blow off the plane, and the Justice Department has begun a criminal investigation .

During the F.A.A.’s examination, the agency deployed as many as 20 auditors at Boeing and roughly half a dozen at Spirit, according to the slide presentation. Boeing assembles the 737 Max at its plant in Renton, Wash., while Spirit builds the plane’s fuselage at its factory in Wichita, Kan.

The audit at Boeing was wide ranging, covering many parts of the 737 Max, including its wings and an assortment of other systems.

Many of the problems found by auditors fell in the category of not following an “approved manufacturing process, procedure or instruction,” according to the presentation. Some other issues dealt with quality-control documentation.

“It wasn’t just paperwork issues, and sometimes it’s the order that work is done,” Mike Whitaker, the F.A.A. administrator, said at a news conference on Monday. “Sometimes it’s tool management — it sounds kind of pedestrian, but it’s really important in a factory that you have a way of tracking tools effectively so that you have the right tool and you know you didn’t leave it behind. So it’s really plant floor hygiene, if you will, and a variety of issues of that nature.”

One audit dealt with the component that blew off the Alaska Airlines jet, known as a door plug . Boeing failed that check, according to the presentation. Some of the issues flagged by that audit related to inspection and quality-control documentation, though the exact findings were not detailed in the presentation.

The F.A.A.’s examination also explored how well Boeing’s employees understood the company’s quality-control processes. The agency interviewed six company engineers and scored their responses, and the overall average score came out to only 58 percent.

One audit at Spirit that focused on the door plug component found five problems. One of those problems, the presentation said, was that Boeing “failed to provide evidence of approval of minor design change under a method acceptable to the F.A.A.” It was not clear from the presentation what the design change was.

Another audit dealt with the installation of the door plug, and it was among those that Spirit failed. The audit raised concerns about the Spirit technicians who carried out the work and found that the company “failed to determine the knowledge necessary for the operation of its processes.”

Other audits that Spirit failed included one that involved a cargo door and another that dealt with the installation of cockpit windows.

Mark Walker is an investigative reporter focused on transportation. He is based in Washington. More about Mark Walker

Boeing: A Company in Turmoil

Boeing is weathering a particularly difficult period: two fatal crashes, a loose panel that blew out during a flight, quality concerns and production slowdowns..

United’s Planes : An engine fire sparked by plastic packaging wrap, a tire lost shortly after takeoff and a plane veering off the runway: These are among several incidents that have occurred over two weeks  on Boeing flights operated by United Airlines.

Alaska Airlines Flight 1282: After a section of a plane headed for Ontario, Calif., blew out  10 minutes after it took off , there was increased scrutiny  on the plane’s manufacturer: Boeing . The Justice Department has since launched a criminal investigation .

Quality Control Issues: An audit that was initiated by the Federal Aviation Administration after the Alaska Airlines incident found dozens of problems  throughout Boeing’s manufacturing process and one of its key suppliers.

Whistleblower’s Death: John Barnett, a former quality manager for the company, was found dead in Charleston  in March with what appeared to be a self-inflicted gunshot wound. He was set to testify in a lawsuit in which he accused Boeing of retaliation for his complaints about quality and safety.

At Fault: A report released in February by the Federal Aviation Administration said that Boeing’s safety culture remains flawed , despite improvements made after two fatal crashes  in 2018 and 2019.

Solving an Enduring Crisis: The Federal Aviation Administration has asked Boeing to produce an action plan  to address quality control issues. We asked experts how Boeing should try and fix its longstanding problems .

Live updates: Hearing on new evidence in Trump N.Y. hush money case

New York Supreme Court Justice Juan Merchan is holding a hearing at 10 a.m. about a late release of more than 100,000 pages of potential evidence in former president Donald Trump’s trial over 2016 hush money payments . A key question is whether he’ll set a new trial date, after delaying jury selection until at least mid-April.

Trump’s lawyers argue the last-minute nature of the documents from an old federal investigation into Trump’s former fixer, Michael Cohen , is such an egregious violation that the charges should be dropped and the district attorney’s office sanctioned.

Prosecutors say that’s nonsensical, and the new material is not key to Trump’s state case.

Here’s what to know

• The trial, which had been scheduled to start today, was pushed back until at least mid-April after the judge said lawyers needed more time to review the large number of documents turned over this month.
• Prosecutors argue that only about 270 pages are significant to the Trump case, in which the former president is accused of using his then-lawyer Cohen to pay for the silence of adult-film star Stormy Daniels about an alleged past sexual liaison.
• The hearing falls on the same day as a key deadline in another Trump case — Trump must come up with cash or a bond of more than $450 million to keep authorities from seizing his assets while he appeals a civil judgment against him. He and his lawyers have sent conflicting signals about whether he can come up with the money.
• Subscribe to The Trump Trials , our weekly email newsletter on Donald Trump’s four criminal cases.

10:02 AM: Analysis from Azi Paybarah, National reporter covering campaigns and breaking politics news.

In brief remarks outside the courthouse, Donald Trump said the case is a “witch hunt” and “a hoax.”

9:58 AM: Analysis from Shayna Jacobs, Courts, law enforcement and criminal justice

Donald Trump has entered the courtroom. He walked down the aisle wearing a glum expression.

9:57 AM: Who is the judge presiding over Trump’s N.Y. criminal case?

New York Supreme Court Justice Juan Merchan is overseeing the case in which Donald Trump is charged with falsifying business records in connection with hush money payments made in 2016.

Merchan, who has sat on the New York bench since 2009, also presided over the 2022 jury trial of Trump’s namesake real estate company , which resulted in a conviction, and the prosecution of the company’s longtime chief financial officer, Allen Weisselberg.

Merchan was born in Colombia, grew up in Jackson Heights in Queens, and attended Baruch College and the Hofstra University School of Law, according to his court biography .

Merchan works at the New York Supreme Court, a felony-level trial court with branches in each New York borough and each county around the state.

As part of his portfolio, Merchan oversees a specialized court that gives treatment options and merit-based plea agreements to eligible defendants who are in the throes of mental illness when they commit crimes. The program prioritizes treatment and recovery. Graduates can have their charges reduced or dismissed.

By: Perry Stein and Shayna Jacobs

9:52 AM: Analysis from Shayna Jacobs, Courts, law enforcement and criminal justice

Manhattan District Attorney Alvin Bragg is now in the courtroom, seated in the gallery. He is with security and some of his aides.

9:43 AM: Analysis from Azi Paybarah, National reporter covering campaigns and breaking politics news.

Donald Trump just arrived at a courthouse in Lower Manhattan, where New York Supreme Court Justice Juan Merchan will hold a hearing on his hush money case.

9:43 AM: Analysis from Shayna Jacobs, Courts, law enforcement and criminal justice

Donald Trump’s lawyers — Todd Blanche, Emil Bove and Clifford Robert — walked into the courtroom a few minutes ago and then left. Trump is still not in the room. For more on Trump’s many defense lawyers, click here .

9:38 AM: Analysis from Devlin Barrett, Reporter focusing on national security and law enforcement

Justice Juan Merchan kicked off a Feb. 15 hearing in this case by declaring that the trial would be held March 25 — a date he later postponed because of the new evidence. It will be interesting to see whether he similarly starts today’s proceeding with a consequential decision or ruling.

9:35 AM: Analysis

Protesters demonstrate outside Manhattan criminal court while awaiting the arrival of former president Donald Trump on Monday.

9:31 AM: Analysis from Shayna Jacobs, Courts, law enforcement and criminal justice

Donald Trump’s attorneys have repeatedly been denied a delay in this case by Justice Juan Merchan, who has been firm about starting the trial on time. Recently, Merchan left open the option of pushing it past mid-April. It will be interesting to see whether his new stance signals concerns other than the parties’ need for time to review new discovery.

9:27 AM: Ex-Trump prosecutor who wrote book recently handed over texts

NEW YORK — Former Donald Trump prosecutor Mark Pomerantz left the Manhattan district attorney’s office about two years ago after resigning in disagreement with how District Attorney Alvin Bragg viewed the long-running Trump investigation he inherited from his predecessor.

Pomerantz then took the unprecedented and widely criticized step of writing a book primarily about his work on Trump-related matters that were still under investigation by Bragg’s reorganized team.

Bragg opted to charge the former president with falsifying business records related to hush money paid to adult-film actress Stormy Daniels in 2016 during Trump’s campaign for president, a focus unrelated to the case Pomerantz wanted to pursue.

Pomerantz’s name resurfaced recently when prosecutors filed a disclosure about text messages he had in his possession during his time as an investigator. Those messages were exchanged with a lawyer for Michael Cohen, Trump’s former fixer who has admitted to paying Daniels on Trump’s behalf to keep an alleged sexual liaison out of the news during the end of the 2016 presidential race.

The texts were redacted from court papers, but Pomerantz submitted a sworn statement explaining that he did not know how to properly search his phone and had missed them in his previous searches.

By: Shayna Jacobs

9:20 AM: New York could still be the first Trump criminal case to go to trial

Even with a delay of a month or more, the New York indictment against Donald Trump could still be the first of his four criminal cases to go to trial, which would be a milestone in U.S. history as the first such trial of a former president.

The New York trial was originally slated to start Monday, but a late revelation about more than 100,000 pages of potential evidence from federal prosecutors forced the judge to push that start date back until April 15 at the earliest.

That could still put the New York case far ahead of the others. In Washington where Trump is charged in federal court with conspiring to overturn the results of the 2020 presidential election, that trial is on hold until probably late summer at the earliest as the Supreme Court weighs the former president’s claims of immunity .

In Florida, where Trump is charged with mishandling classified papers and obstructing government efforts to retrieve them, the trial judge has yet to resolve a host of legal issues before a trial can begin, and national security law experts increasingly believe the pace of her work means that trial is still many months away.

In Georgia, where Trump is charged with conspiring to overturn the election results in that state, the judge has yet to set a trial date and has spent the past two months on a long legal detour about whether prosecutors acted ethically .

In New York, Trump’s lawyers are asking for months more to review the large volume of material provided by federal prosecutors. They also seek a dismissal of the case entirely and sanctions against the district attorney for not providing the documents earlier.

It will be up to New York Supreme Court Justice Juan Merchan to weigh all of those arguments and make a decision about whether, how and when the case will proceed.

By: Devlin Barrett

9:18 AM: Analysis from Shayna Jacobs, Courts, law enforcement and criminal justice

Reporters filed into the courtroom before 9 a.m. as prosecutors were setting up their table with binders and what appeared to be a visual presentation. Today’s arguments are expected to last hours.

9:10 AM: Evidence about Michael Cohen is at the center of today’s Trump hearing

Donald Trump’s former lawyer and fixer has a key role in the upcoming trial, and a key role in the current dispute over newly shared potential evidence.

Michael Cohen was investigated and prosecuted by federal authorities in New York during the Trump administration, and he eventually pleaded guilty to a host of charges, including lying to Congress and campaign finance violations.

The Manhattan district attorney’s case against Trump is focused on some of the same conduct that led to the federal case against Cohen.

Trump’s lawyers asked for the evidence gathered by federal investigators, and after a back-and-forth, federal prosecutors turned over more than 100,000 pages of documents, including detailed notes of what Cohen told then-special counsel Robert S. Mueller III when Mueller was looking for any ties between Russian election interference efforts in 2016 and the Trump campaign.

Trump’s lawyers argue the new material is critical evidence that should have been turned over long ago, while the Manhattan district attorney says the vast majority of the documents are irrelevant or duplicative of information Trump’s team already has.

At Monday’s hearing, New York Supreme Court Justice Juan Merchan will hear from each side to decide what the next step should be: hold a trial, give the defense more time to prepare, or toss out the case.

9:03 AM: Analysis from Azi Paybarah, National reporter covering campaigns and breaking politics news.

Donald Trump complained about his legal woes hours before his latest court case gets underway in Manhattan. On Truth Social, the former president called the cases against him “Rigged,” adding, “I DID NOTHING WRONG!” and “Our Country is CORRUPT.”

8:59 AM: DA Bragg expected to argue no trial delay needed in hush money case

NEW YORK — Manhattan District Attorney Alvin Bragg recently agreed to a three-week delay in the start of Donald Trump’s hush money trial because more than 100,000 documents were turned over to the defense by federal authorities after preparation for the proceeding was well underway.

New York Supreme Court Justice Juan Merchan granted that delay but ordered the parties to appear Monday — the day jury selection was supposed to start — for arguments about who was to blame for the 11th-hour document dump .

Bragg has since said that no further delay is necessary , arguing in court papers that Merchan should stick to the mid-April start.

Trump’s lawyers said in a recent filing that the delay should be three months, which would push off the trial start into June. The same attorneys are expected to argue in court Monday that a further delay is necessary because their review of the documents is not complete.

Trump’s defense team also accuses prosecutors of violating discovery rules even though the documents were provided by the U.S. attorney’s office in Manhattan that previously investigated the same conduct, not Bragg’s team. Bragg’s side has said it did not have possession of the records that were recently turned over and that the prosecution did not fail to meet its legal obligations.

Merchan left open the possibility for a delay beyond the mid-April start date he recently ordered. In past proceedings, the judge signaled a firm intention to ensure the trial starts on time, denying several requests by the defense to postpone the trial date.

8:57 AM: Trump faces unofficial $450 million bond deadline on Monday

NEW YORK — Donald Trump owes more than $450 million to the state of New York after losing a major civil business fraud case that accused the former president and his company of deceiving business partners to increase profits and savings.

New York Attorney General Letitia James brought a major lawsuit in 2022 against Trump, his company and several current and former executives, accusing them of purposely inflating the value of Trump’s properties by up to $2.2 billion a year from 2011 to 2021.

James could have begun the process of seizing Trump’s assets when the judgment was finalized a month ago, but her office was expected to adhere to a customary grace period of 30 days. which ended over the weekend.

Trump owns several major properties in New York, including Trump Tower on Fifth Avenue, 40 Wall Street downtown and Seven Springs, a sprawling private estate in Westchester County.

Trump could stop James from executing the judgment by posting an appeal bond, which the former president’s attorneys said has been impossible because of the size of a bond required and restrictions bond companies were imposing.

Trump’s lawyers said last week that after consulting with 30 bond surety companies through four brokers, none agreed to issue Trump a bond using parts of his real estate portfolio as collateral.

On Friday, however, Trump undercut his lawyers’ statements that he wouldn’t be able to pay the bond, claiming in a social media post that he has “almost $500 million” in cash .

A full panel is expected to review that issue but it is unclear whether it will rule before James starts the collection process.

8:55 AM: What Donald Trump is charged with in this case

Donald Trump faces 34 counts of falsifying business records , a felony under New York law when the purpose of the fraud is to “commit another crime or to aid or conceal” an illegal act.

Manhattan District Attorney Alvin Bragg has charged that Trump oversaw a scheme during the 2016 presidential campaign to pay money to adult-film star Stormy Daniels to keep quiet about an alleged past sexual liaison, and later caused false records to be kept about those payments.

The conduit for those payments was Michael Cohen, Trump’s then lawyer and fixer, who arranged the payment and was reimbursed. Bragg said those transactions were election law violations that were falsely designed to look like legal fees.

Trump has pleaded not guilty and denied all wrongdoing. He has complained that the New York charges — and the three other indictments he faces — are politically motivated efforts to derail his White House candidacy.

Read more about the hush money case and the key people involved .