majority of fetal presentation will be

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

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

Fetal presentation and position

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

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

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

Medical illustrations by Jonathan Dimes

Head down, facing down (anterior position)

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

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

Head down, facing up (posterior position)

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

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

Frank breech

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

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

Complete breech

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

Incomplete breech

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

Single footling breech

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

Double footling breech

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

Transverse lie

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

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

Oblique lie

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

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

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What to know if your baby is breech

What's a sunny-side up baby?

What happens to your baby right after birth

How your twins’ fetal positions affect labor and delivery

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

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

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

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

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

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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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• Fetal presentation before birth

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

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

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

Head down, face down

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

Head down, face up

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

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

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

Frank breech

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

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

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

Complete and incomplete breech

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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Variation in fetal presentation

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At the time the article was created The Radswiki had no recorded disclosures.

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• Delivery presentations
• Variation in delivary presentation
• Abnormal fetal presentations

There can be many variations in the fetal presentation which is determined by which part of the fetus is projecting towards the internal cervical os . This includes:

cephalic presentation : fetal head presenting towards the internal cervical os, considered normal and occurs in the vast majority of births (~97%); this can have many variations which include

left occipito-anterior (LOA)

left occipito-posterior (LOP)

left occipito-transverse (LOT)

right occipito-anterior (ROA)

right occipito-posterior (ROP)

right occipito-transverse (ROT)

straight occipito-anterior

straight occipito-posterior

breech presentation : fetal rump presenting towards the internal cervical os, this has three main types

frank breech presentation  (50-70% of all breech presentation): hips flexed, knees extended (pike position)

complete breech presentation  (5-10%): hips flexed, knees flexed (cannonball position)

footling presentation  or incomplete (10-30%): one or both hips extended, foot presenting

other, e.g one leg flexed and one leg extended

shoulder presentation

cord presentation : umbilical cord presenting towards the internal cervical os

• 1. Fox AJ, Chapman MG. Longitudinal ultrasound assessment of fetal presentation: a review of 1010 consecutive cases. Aust N Z J Obstet Gynaecol. 2006;46 (4): 341-4. doi:10.1111/j.1479-828X.2006.00603.x - Pubmed citation
• 2. Merz E, Bahlmann F. Ultrasound in obstetrics and gynecology. Thieme Medical Publishers. (2005) ISBN:1588901475. Read it at Google Books - Find it at Amazon

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• Introduction
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• External Cephalic Version
• Management of Labor And Delivery
• Cesarean Delivery
• Perinatal Outcome
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Abnormal Lie/Presentation

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INTRODUCTION

The mechanism of labor and delivery, as well as the safety and efficacy, is determined by the specifics of the fetal and maternal pelvic relationship at the onset of labor. Normal labor occurs when regular and painful contractions cause progressive cervical dilatation and effacement, accompanied by descent and expulsion of the fetus. Abnormal labor involves any pattern deviating from that observed in the majority of women who have a spontaneous vaginal delivery and includes:

• Protraction disorders (slower than normal progress);
• Arrest disorders (complete cessation of progress).

Among the causes of abnormal labor is the disproportion between the presenting part of the fetus and the maternal pelvis, which rather than being a true disparity between fetal size and maternal pelvic dimensions, is usually due to a malposition or malpresentation of the fetus.

This chapter reviews how to define, diagnose, and manage the clinical impact of abnormalities of fetal lie and malpresentation with the most commonly occurring being the breech-presenting fetus.

DEFINITIONS

At the onset of labor, the position of the fetus in relation to the birth canal is critical to the route of delivery and, thus, should be determined early. Important relationships include fetal lie, presentation, attitude, and position .

Fetal lie describes the relationship of the fetal long axis to that of the mother. In more than 99% of labors at term, the fetal lie is longitudinal . A transverse lie is less frequent when the fetal and maternal axes may cross at a 90 ° angle, and predisposing factors include multiparity, placenta previa, hydramnios, and uterine anomalies. Occasionally, the fetal and maternal axes may cross at a 45 ° angle, forming an oblique lie . 

Fetal presentation

The presenting part is the portion of the fetal body that is either foremost within the birth canal or in closest proximity to it. Thus, in longitudinal lie, the presenting part is either the fetal head or the breech, creating cephalic and breech presentations , respectively. The shoulder is the presenting part when the fetus lies with the long axis transversely.

Commonly the baby lies longitudinally with cephalic presentation. However, in some instances, a fetus may be in breech where the fetal buttocks are the presenting part. Breech fetuses are also referred to as malpresentations. Fetuses that are in a transverse lie may present the fetal back (or shoulders, as in the acromial presentation), small parts (arms and legs), or the umbilical cord (as in a funic presentation) to the pelvic inlet. When the fetal long axis is at an angle to the bony inlet, and no palpable fetal part generally is presenting, the fetus is likely in oblique lie. This lie usually is transitory and occurs during fetal conversion between other lies during labor.

The point of direction is the most dependent portion of the presenting part. In cephalic presentation in a well-flexed fetus, the occiput is the point of direction.

The fetal position refers to the location of the point of direction with reference to the four quadrants of the maternal outlet as viewed by the examiner. Thus, position may be right or left as well as anterior or posterior.

Unstable lie

Refers to the frequent changing of fetal lie and presentation in late pregnancy (usually refers to pregnancies >37 weeks).

Fetal position

Fetal position refers to the relationship of an arbitrarily chosen portion of the fetal presenting part to the right or left side of the birth canal. With each presentation there may be two positions – right or left. The fetal occiput, chin (mentum) and sacrum are the determining points in vertex, face, and breech presentations. Thus:

• left and right occipital presentations
• left and right mental presentations
• left and right sacral presentations.

Fetal attitude

The fetus instinctively forms an ovoid mass that corresponds to the shape of the uterine cavity towards the third trimester, a characteristic posture described as attitude or habitus. The fetus becomes folded upon itself to create a convex back, the head is flexed, and the chin is almost in contact with the chest. The thighs are flexed over the abdomen and the legs are bent at the knees. The arms are usually parallel to the sides or lie across the chest while the umbilical cord fills the space between the extremities. This posture is as a result of fetal growth and accommodation to the uterine cavity. It is possible that the fetal head can become progressively extended from the vertex to face presentation resulting in a change of fetal attitude from convex (flexed) to concave (extended) contour of the vertebral column.

The categories of frank, complete, and incomplete breech presentations differ in their varying relations between the lower extremities and buttocks (Figure 1). With a frank breech, lower extremities are flexed at the hips and extended at the knees, and thus the feet lie close to the head. With a complete breech, both hips are flexed, and one or both knees are also flexed. With an incomplete breech, one or both hips are extended. As a result, one or both feet or knees lie below the breech, such that a foot or knee is lowermost in the birth canal. A footling breech is an incomplete breech with one or both feet below the breech.

Types of breech presentation. Reproduced from WHO 2006, 1 with permission.

The relative incidence of differing fetal and pelvic relations varies with diagnostic and clinical approaches to care.

About 1 in 25 fetuses are breech at the onset of labor and about 1 in 100 are transverse or oblique, also referred to as non-axial. 2

With increasing gestational age, the prevalence of breech presentation decreases. In early pregnancy the fetus is highly mobile within a relatively large volume of amniotic fluid, therefore it is a common finding. The incidence of breech presentation is 20–25% of fetuses at <28 weeks, but only 7–16% at 32 weeks, and only 3–4% at term. 2 , 3

Face and brow presentation are uncommon. Their prevalence compared with other types of malpresentations are shown below. 4

• Occiput posterior – 1/19 deliveries;
• Breech – 1/33 deliveries;
• Face – 1/600–1/800 deliveries;
• Brow – 1/500–1/4000 deliveries;
• Transverse lie – 1/833 deliveries;
• Compound – 1/1500 deliveries.

Transverse lie is often unstable and fetuses in this lie early in pregnancy later convert to a cephalic or breech presentation.

The fetus has a relatively larger head than body during most of the late second and early third trimester, it therefore tends to spend much of its time in breech presentation or in a non-axial lie as it rotates back and forth between cephalic and breech presentations. The relatively large volume of amniotic fluid present facilitates this dynamic presentation.

Abnormal fetal lie is frequently seen in multifetal gestation, especially with the second twin. In women of grand parity, in whom relaxation of the abdominal and uterine musculature tends to occur, a transverse lie may be encountered. Prematurity and macrosomia are also predisposing factors. Distortion of the uterine cavity shape, such as that seen with leiomyomas, prior uterine surgery, or developmental anomalies (Mullerian fusion defects), predisposes to both abnormalities in fetal lie and malpresentations. The location of the placenta also plays a contributing role with fundal and cornual implantation being seen more frequently in breech presentation. Placenta previa is a well-described affiliate for both transverse lie and breech presentation.

Fetuses with congenital anomalies also present with abnormalities in either presentation or lie. It is possibly as a cause (i.e. fitting the uterine cavity optimally) or effect (the fetus with a neuromuscular condition that prevents the normal turning mechanism). The finding of an abnormal lie or malpresentation requires a thorough search for fetal abnormalities. Such abnormalities could include chromosomal (autosomal trisomy) and structural abnormalities (hydrocephalus), as well as syndromes of multiple effects (fetal alcohol syndrome).

In most cases, breech presentation appears to be as a chance occurrence; however, up to 15% may be owing to fetal, maternal, or placental abnormalities. It is commonly thought that a fetus with normal anatomy, activity, amniotic fluid volume, and placental location adopts the cephalic presentation near term because this position is the best fit for the intrauterine space, but if any of these variables is abnormal, then breech presentation is more likely.

Factors associated with breech presentation are shown in Table 1.

Risk factors for breech presentation.

Spontaneous version may occur at any time before delivery, even after 40 weeks of gestation. A prospective longitudinal study using serial ultrasound examinations reported the likelihood of spontaneous version to cephalic presentation after 36 weeks was 25%. 5

In population-based registries, the frequency of breech presentation in a second pregnancy was approximately 2% if the first pregnancy was not a breech presentation and approximately 9% if the first pregnancy was a breech presentation. After two consecutive pregnancies with breech presentation at delivery, the risk of another breech presentation was approximately 25% and this rose to 40% after three consecutive breech deliveries. 6 , 7

In addition, parents who themselves were delivered at term from breech presentation were twice as likely to have their offspring in breech presentation as parents who were delivered in cephalic presentation. This suggests a possible heritable component to fetal presentation. 8

Leopold’s maneuvers

The Leopold’s maneuvers: palpation of fetus in left occiput anterior position. Reproduced from World Health Organization, 2006, 1   with permission.

Abdominal examination can be conducted systematically employing the four maneuvers described by Leopold in 1894. 9 , 10 In obese patients, in polyhydramnios patients or those with anterior placenta, these maneuvers are difficult to perform and interpret.

The first maneuver is to assess the uterine fundus. This allows the identification of fetal lie and determination of which fetal pole, cephalic or podalic – occupies the fundus. In breech presentation, there is a sensation of a large, nodular mass, whereas the head feels hard and round and is more mobile.

The second maneuver is accomplished as the palms are placed on either side of the maternal abdomen, and gentle but deep pressure is exerted. On one side, a hard, resistant structure is felt – the back. On the other, numerous small, irregular, mobile parts are felt – the fetal extremities. By noting whether the back is directed anteriorly, transversely, or posteriorly, fetal orientation can be determined.

The third maneuver aids confirmation of fetal presentation. The thumb and fingers of one hand grasp the lower portion of the maternal abdomen just above the symphysis pubis. If the presenting part is not engaged, a movable mass will be felt, usually the head. The differentiation between head and breech is made as in the first maneuver.

The fourth maneuver helps determine the degree of descent. The examiner faces the mother’s feet, and the fingertips of both hands are positioned on either side of the presenting part. They exert inward pressure and then slide caudad along the axis of the pelvic inlet. In many instances, when the head has descended into the pelvis, the anterior shoulder or the space created by the neck may be differentiated readily from the hard head.

According to Lyndon-Rochelle et al ., 11 experienced clinicians have accurately identified fetal malpresentation using Leopold maneuvers with a high sensitivity 88%, specificity 94%, positive-predictive value 74%, and negative-predictive value 97%.

Vaginal examination

Prelabor diagnosis of fetal presentation is difficult as the presenting part cannot be palpated through a closed cervix. Once labor begins and the cervix dilates, and palpation through vaginal examination is possible. Vertex presentations and their positions are recognized by palpation of the various fetal sutures and fontanels, while face and breech presentations are identified by palpation of facial features or the fetal sacrum and perineum, respectively.

Sonography and radiology

Sonography is the gold standard for identifying fetal presentation. This can be done during antenatal period or intrapartum. In obese women or in women with muscular abdominal walls this is especially important. Compared with digital examinations, sonography for fetal head position determination during second stage labor is more accurate. 12 , 13

COMPLICATIONS

Adverse outcomes in malpresented fetuses are multifactorial. They could be due to either underlying conditions associated with breech presentation (e.g., congenital anomalies, intrauterine growth restriction, preterm birth) or trauma during delivery.

Neonates who were breech in utero are more at risk for mild deformations (e.g., frontal bossing, prominent occiput, upward slant and low-set ears), torticollis, and developmental dysplasia of the hip.

Other obstetric complications include prolapse of the umbilical cord, intrauterine infection, maldevelopment as a result of oligohydramnios, asphyxia, and birth trauma and all are concerns.

Birth trauma especially to the head and cervical spine, is a significant risk to both term and preterm infants who present breech. In cephalic presenting fetuses, the labor process prepares the head for delivery by causing molding which helps the fetus to adapt to the birth canal. Conversely, the after-coming head of the breech fetus must descend and deliver rapidly and without significant change in shape. Therefore, small alterations in the dimensions or shape of the maternal bony pelvis or the attitude of the fetal head may have grave consequences. This process poses greater risk to the preterm infant because of the relative size of the fetal head and body. Trauma to the head is not eliminated by cesarean section; both intracranial and cervical spine trauma may result from entrapment in either the uterine or abdominal incisions.

In resource-limited countries where ultrasound imaging, urgent cesarean delivery, and neonatal intensive care are not readily available, the maternal and perinatal mortality/morbidity associated with transverse lie in labor can be high. Uterine rupture from prolonged labor in a transverse lie is a major reason for maternal/perinatal mortality and morbidity.

EXTERNAL CEPHALIC VERSION

External cephalic version (ECV) is the manual rotation of the fetus from a non-cephalic to a cephalic presentation by manipulation through the maternal abdomen (Figure 3).

External version of breech presentation . Reproduced from WHO 2003 , 14  with  permission .

This procedure is usually performed as an elective procedure in women who are not in labor at or near term to improve their chances of having a vaginal cephalic birth. ECV reduces the risk of non-cephalic presentation at birth by approximately 60% (relative risk [RR] 0.42, 95% CI 0.29–0.61) and reduces the risk of cesarean delivery by approximately 40% (RR 0.57, 95% CI 0.40–0.82). 7

In a 2008 systematic review of 84 studies including almost 13,000 version attempts at term, the pooled success rate was 58%. 15  

A subsequent large series of 2614 ECV attempts over 18 years reported a success rate of 49% and provided more details): 16

• The success rate was 40% in nulliparous women and 64% in parous women.
• After successful ECV, 97% of fetuses remained cephalic at birth, 86% of which were delivered vaginally.
• Spontaneous version to a cephalic presentation occurred after 4.3% of failed attempts, and 2.2% of successfully vertexed cases reverted to breech.

Factors associated with lower ECV success rates include nulliparity, anterior placenta, lateral or cornual placenta, decreased amniotic fluid volume, low birth weight, obesity, posteriorly located fetal spine, frank breech presentation, ruptured membranes.

The following factors should be considered while managing malpresentations: type of malpresentation, gestational age at diagnosis, availability of skilled personnel, institutional resources and protocols and patient factors and preferences.

Breech presentation

According to a term breech trial, 17 planned cesarean delivery carries a reduced perinatal mortality and early neonatal morbidity for babies with breech presentation at term compared to vaginal breech delivery. When planning a breech vaginal birth, appropriate patient selection and skilled personnel in breech delivery are key in achieving good neonatal outcomes. In appropriately selected patients and skilled personnel in vaginal breech deliveries, perinatal mortality is between 0.8 and 1.7/1000 for planned vaginal breech birth and between 0 and 0.8/1000 for planned cesarean section. 18 , 19 The choice of the route of delivery should therefore be made considering the availability of skilled personnel in conducting breech vaginal delivery; providing competent newborn care; conducting rapid cesarean delivery should need arise and performing ECV if desired; availability of resources for continuous intrapartum fetal heart rate and labor monitoring; patient clinical features, preferences and values; and institutional policies, protocols and resources.

Four approaches to the management of breech presentation are shown in Figure 4: 8

Management of breech presentation. ECV, external cephalic version.

The options available are:

• Attempting external cephalic version (ECV) before labor with a trial of labor if successful and conducting cesarean delivery if unsuccessful.
• Footling or kneeling breech presentation;
• Fetal macrosomia;
• Fetal growth restriction;
• Hyperextended fetal neck in labor;
• Previous cesarean delivery;
• Unavailability of skilled personnel in breech delivery;
• Other contraindications to vaginal delivery like placenta previa, cord prolapse;
• Fetal anomaly that may interfere with vaginal delivery like hydrocephalus.
• Planned cesarean delivery without an attempt at ECV.
• Planned trial of vaginal breech delivery in patients with favorable clinical characteristics for vaginal delivery without an attempt at ECV.

All the four approaches should be discussed in detail with the patient, and in light of all the considerations highlighted above, a safe plan of care agreed upon by both the patient and the clinician in good time.

Transverse and oblique lie

If a diagnosis of transverse/oblique fetal lie is made before onset of labor and there are no contraindications to vaginal birth or ECV, ECV can be attempted at 37 weeks' gestation. If the malpresentation recurs, further attempts at ECV can be made at 38–39 weeks with induction of labor if successful.

ECV can also be attempted in early labor with intact fetal membranes and no contraindications to vaginal birth.

If ECV is declined or is unsuccessful, then planned cesarean section should be arranged after 39 weeks' gestation.

MANAGEMENT OF LABOR AND DELIVERY

Skills to conduct vaginal breech delivery are very important as there are women who may opt for planned vaginal breech birth and even among those who choose planned cesarean delivery, about 10% may go into labor and end up with a vaginal breech delivery. 17 Some implications of cesarean delivery such as need for repeat cesarean deliveries, placental attachment disorders and uterine rupture make vaginal birth more desirable to some individuals. In addition, vaginal birth has advantages such as affordability, quicker recovery, shorter hospital stay, less complications and is more favorable for resource poor settings.

In appropriately selected women, planned vaginal breech birth is not associated with any significant long-term neurological morbidity. Regardless of planned mode of birth, cerebral palsy occurs in approximately 1.5/1,000 breech births, and abnormal neurological development occurs in approximately 3/100. 18 Careful patient selection is very important for good outcomes and it is generally agreed that women who choose to undergo a trial of labor and vaginal breech delivery should be at low risk of complications from vaginal breech delivery. Some contraindications to vaginal breech delivery have been highlighted above.

Women with breech presentation near term, pre- or early-labor ultrasound should be performed to assess type of breech presentation, flexion of the fetal head and fetal growth. If a woman presents in labor and ultrasound is unavailable and has not recently been performed, cesarean section is recommended. Vaginal breech deliveries should only take place in a facility with ability and resources readily available for emergency cesarean delivery should the need arise.

Induction of labor may be considered in carefully selected low-risk women. Augmentation of labor is controversial as poor progress of labor may be a sign of cephalo-pelvic disproportion, however, it may be considered in the event of weak contractions. A cesarean delivery should be performed if there is poor progress of labor despite adequate contractions. Labor analgesia including epidural can be used as needed.

Vaginal breech delivery should be conducted in a facility that is able to carry out continuous electronic fetal heart rate monitoring sufficient personnel to monitor the progress of labor. From the term breech trial, 17 the commonest indications for cesarean section are poor progress of labor (50%) and fetal distress (29%). There is an increased risk of cord compression which causes variable decelerations. Since the fetal head is at the fundus where contractions begin, the incidence of early decelerations arising from head compression is also higher. Due to the irregular contour of the presenting part which presents a high risk of cord prolapse, immediate vaginal examination should be undertaken if membranes rupture to rule out cord prolapse. The frequency of cord prolapse is 1% with frank breech and more than 10% in footling breech. 8

Fetal blood sampling from the buttocks is not recommended. A passive second stage of up to 90 minutes before active pushing is acceptable to allow the breech to descend well into the pelvis. Once active pushing commences, delivery should be accomplished or imminent within 60 minutes. 18

During planned vaginal breech birth, a skilled clinician experienced in vaginal breech birth should supervise the first stage of labor and be present for the active second stage of labor and delivery. Staff required for rapid cesarean section and skilled neonatal resuscitation should be in-hospital during the active second stage of labor.

The optimum maternal position in second stage has not been extensively studied. Episiotomy should be undertaken as needed and only after the fetal anus is visible at the vulva. Breech extraction of the fetus should be avoided. The baby should be allowed to deliver spontaneously with maternal effort only and without any manipulations at least until the level of the umbilicus. A loop of the cord is then pulled to avoid cord compression. After this point, suprapubic pressure can be applied to facilitate flexion of the fetal head and descent.

Delay of arm delivery can be managed by sweeping them across the face and downwards towards in front of the chest or by holding the fetus at the hips or bony pelvis and performing a 180° rotation to deliver the first arm and shoulder and then in the opposite direction so that the other arm and shoulder can be delivered i.e.,  Lovset’s maneuver (Figure 5).

Lovset’s maneuver. Reproduced from WHO 2006 , 1  with  permission . 

The fetal head can deliver spontaneously or by the following maneuvers:

• Turning the body to the floor with application of suprapubic pressure to flex the head and neck.

Mauriceau-smellie-veit maneuver . Reproduced from WHO 2003, 14 with permission.

• By use of Piper’s forceps.
• Burns-Marshall maneuver  where the baby’s legs and trunk are allowed to hang until the nape of the neck is visible at the mother’s perineum so that its weight exerts gentle downwards and backwards traction to promote flexion of the head. The fetal trunk is then swept in a wide arc over the maternal abdomen by grasping both the feet and maintaining gentle traction; the aftercoming head is slowly born in this process.

If the above methods fail to deliver the fetal head, symphysiotomy and zavanelli maneuver with cesarean section can be attempted. Duhrssen incisions where 1–3 full length incisions are made on an incompletely dilated cervix at the 6, 2 and 10 o’clock positions can be done especially in preterm.

Face presentation

The diagnosis of face presentation is made during vaginal examination where the presenting portion of the fetus is the fetal face between the orbital ridges and the chin. At diagnosis, 60% of all face presentations are mentum anterior, 26% are mentum posterior and 15% are mentum transverse. Since the submentobregmatic (face presentation) and suboccipitobregmatic (vertex presentation) have the same diameter of 9.5 cm, most face presentations can have a successful vaginal birth and not necessarily require cesarean section delivery. 6 The position of a fetus in face presentation helps in guiding the management plan. Over 75% of mentum anterior presentations will have a successful vaginal delivery, whereas it is impossible to have a vaginal birth in mentum posterior position unless it converts spontaneously to mentum anterior position. In mentum posterior position the neck is maximally extended and cannot extend further to deliver beneath the symphysis pubis (Figure 7).

Face presentation. Reproduced from WHO 2003, 14 with permission.

As in breech management, face presentation also requires continuous fetal heart rate monitoring, since abnormalities of fetal heart rate are more common. 5 , 6 In one study , 20 only 14% of pregnancies had normal tracings, 29% developed variable decelerations and 24% had late decelerations. Internal fetal heart rate monitoring with an electrode is not recommended, as it may cause facial and ophthalmic injuries if incorrectly placed. Labor augmentation and cesarean sections are performed as per standard obstetric indications. Vacuum and midforceps delivery should be avoided, but an outlet forceps delivery can be attempted. Attempts to manually convert the face to vertex or to rotate a posterior position to a more favorable anterior mentum position are rarely successful and are associated with high fetal morbidity and mortality, and maternal morbidity, including cord prolapse, uterine rupture, and fetal cervical spine injury with neurological impairment.

Brow presentation

The diagnosis of brow presentation is made during vaginal examination in second stage of labor where the presenting portion of the fetal head is between the orbital ridge and the anterior fontanel.

Brow presentation may be encountered early in labor, but is usually a transitional state and converts to a vertex presentation after the fetal neck flexes. Occasionally, further extension may occur resulting in a face presentation. The majority of brow presentations diagnosed early in labor convert to a more favorable presentation and deliver vaginally. Once brow presentation is confirmed, continuous fetal heart rate monitoring is necessary and labor progress should be monitored closely in order to pick any signs of abnormal labor. Since the brow diameter is large (13.5 cm), persistent brow presentation usually results in prolonged or arrested labor requiring a cesarean delivery. Labor augmentation and instrumental deliveries are therefore not recommended.

CESAREAN DELIVERY

This is an option for women with breech presentation at term to choose cesarean section as their preferred mode of delivery, for those with unsuccessful ECV who do not want to attempt vaginal breech delivery, have contraindications for vaginal breech delivery or in the event that there is no available skilled personnel to safely conduct a vaginal breech delivery. Women should be given enough and accurate information about pros and cons for both planned cesarean section and planned vaginal delivery to help them make an informed decision.

Since the publication of the term breech trial, 17 , 19 there has been a dramatic global shift from selective to planned cesarean delivery for women with breech presentation at term. This study revealed that planned cesarean section carried a reduced perinatal mortality and early neonatal morbidity for babies with breech presentation at term compared to planned vaginal birth (RR 0.33, 95% CI 0.19–0.56). The cesarean delivery rate for breech presentation is now about 70% in European countries, 95% in the United States and within 2 months of the study’s publication, there was a 50–80% increase in rates of cesarean section for breech presentation in The Netherlands.

A planned cesarean delivery should be scheduled at term between 39–41 weeks' gestation to allow maximum time for spontaneous cephalic version and minimize the risk of neonatal respiratory problems. 8 Physical exam and ultrasound should be performed immediately prior to the surgery to confirm the fetal presentation. A detailed consent should be obtained prior to surgery and should include both short- and long-term complications of cesarean section and the alternatives of care that are available. The abdominal and uterine incisions should be sufficiently large to facilitate easy delivery. Thereafter, extraction of the fetus is similar to what is detailed above for vaginal delivery.

Cesarean section for face presentation is indicated for persistent mentum posterior position, mentum transverse and some mentum anterior positions where there is standard indication for cesarean section.

Persistent brow presentation usually necessitates cesarean delivery due to the large presenting diameter that causes arrest or protracted labor.

Transverse/oblique lie

Cesarean section is indicated for patients who present in active labor, in those who decline ECV, following an unsuccessful ECV or in those with contraindications to vaginal birth.

For dorsosuperior (back up) transverse lie, a low transverse incision is made on the uterus and an attempt to grasp the fetal feet with footling breech extraction is made. If this does not succeed, a vertical incision is made to convert the hysterotomy into an inverted T incision.

Dorsoinferior (back down) transverse lie is more difficult to deliver since the fetal feet are hard to grasp. An attempt at intraabdominal version to cephalic or breech presentation can be done if membranes are intact before the uterine incision is made. Another option is to make a vertical uterine incision; however, the disadvantage of this is the risk of uterine rupture in subsequent pregnancies.

PERINATAL OUTCOME

Availability of skilled neonatal care at delivery is important for good perinatal outcomes to facilitate resuscitation if needed for all fetal malpresentations. 8 All newborns born from fetal malpresentations require a thorough examination to check for possible injuries resulting from birth or as the cause of the malpresentation.

Neonates who were in face presentation often have facial edema and bruising/ecchymosis from vaginal examinations that usually resolve within 24–48 hours of life and low Apgar scores. Trauma during labor may cause tracheal and laryngeal edema immediately after delivery, which can result in neonatal respiratory distress and difficulties in resuscitative efforts.

PRACTICE RECOMMENDATIONS

• Diagnosis of unstable lie is made when a varying fetal lie is found on repeated clinical examination in the last month of pregnancy.
• Consider external version to correct lie if not longitudinal.
• Consider ultrasound to exclude mechanical cause.
• Inform woman of need for prompt admission to hospital if membranes rupture or when labor starts.
• If spontaneous rupture of membranes occurs, perform vaginal examination to exclude the presence of a cord or malpresentation.
• If the lie is not longitudinal in labor and cannot be corrected perform cesarean section.

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Malpresentation

• Angela Yulia 4 ,
• Kasia Maksym 5 &
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Pilliod RA, Caughey AB. Fetal malpresentation and malposition: diagnosis and management. Obstet Gynecol Clin North Am. 2017;44:631–43.

Article   Google Scholar  

Chebsey CS, Fox R; TJ Draycott, Siassakos D, Winter C on behalf of the Royal College of Obstetricians and Gynaecologists. Umbilical Cord Prolapse. Green-top guideline No. 50. London: RCOG; 2014.

Google Scholar  

Szaboova R, Sankaran S, Harding K, et al. PLD.23 Management of transverse and unstable lie at term. Archives of Disease in Childhood - Fetal and Neonatal Edition 2014;99:A112–3.

Impey LWM, Murphy DJ, Griffiths M, Penna LK on behalf of the Royal College of Obstetricians and Gynaecologists. Management of Breech Presentation. Green-top guideline No. 20b. BJOG. 2017; 124:e151–77.

Ford J, Roberts C, Nassar N, Giles W, Morris J. Recurrence of breech presentation in consecutive pregnancies. BJOG. 2010;117:830–6.

Article   CAS   Google Scholar  

Impey LWM, Murphy DJ, Griffiths M, Penna LK on behalf of the Royal College of Obstetricians and Gynaecologists. External Cephalic Version and Reducing the Incidence of Term Breech Presentation. Green-top guideline 20a. BJOG 2017; 124: e178–92.

Hannah ME, Hannah WJ, Hewson SA, Hodnett ED, Saigal S, Willan AR, et al. Planned caesarean section versus planned vaginal birth for breech presentation at term: a randomised multicentre trial. Term Breech Trial Collaborative Group. Lancet. 2000;356 (9239):1375–83.

Patterson-Brown S, Howell C. Managing Obstetric Emergencies and Trauma (MOET), The MOET Course Manual 2016, 3rd Edition. Breech delivery and external cephalic version. Chapter 34: pp 401–414. Cambridge University Press.

Bohren MA, Hofmeyr GJ, Sakala C, Fukuzawa RK, Cuthbert A. Continuous support for women during childbirth. Cochrane Database Syst Rev 2017;(7):CD003766.

Smith GN, Brien JF. Use of nitroglycerin for uterine relaxation. Obstet Gynecol Surv. 1998;53(9):559–65.

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

Study session 8  abnormal presentations and multiple pregnancies, introduction.

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

Learning Outcomes for Study Session 8

After studying this session, you should be able to:

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

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

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

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

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

8.1  Normal and abnormal presentations

8.1.1  vertex presentation.

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

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

8.1.2  Malpresentations

You will learn about obstructed labour in Study Session 9.

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

8.1.3  Malposition

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

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

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

8.2  Causes and consequences of malpresentations and malpositions

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

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

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

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

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

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

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

8.3  Breech presentation

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

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

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

8.3.1  Causes of breech presentation

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

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

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

8.3.2  Diagnosis of breech presentation

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

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

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

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

8.3.3  Types of breech presentation

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

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

8.3.4  Risks of breech presentation

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

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

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

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

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

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

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

8.4  Face presentation

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

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

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

8.4.1  Causes of face presentation

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

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

8.4.2  Diagnosis of face presentation

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

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

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

8.4.3  Complications of face presentation

Complications for the fetus include:

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

8.5  Brow presentation

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

8.5.1  Possible causes of brow presentation

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

• Lax uterus due to repeated full term pregnancy
• Polyhydramnios

8.5.2  Diagnosis of brow presentation

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

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

8.5.3  Complications of brow presentation

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

• Cerebral haemorrhage.

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

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

8.6  Shoulder presentation

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

8.6.1  Causes of shoulder presentation

Causes of shoulder presentation could be maternal or fetal factors.

Maternal factors include:

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

Fetal factors include:

• Preterm labour
• Placenta previa.

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

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

8.6.2  Diagnosis of shoulder presentation

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

8.6.3  Complications of shoulder presentation

Complications include:

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

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

8.7  Multiple pregnancy

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

8.7.1  Types of twin pregnancy

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

8.7.2  Diagnosis of twin pregnancy

On abdominal examination you may notice that:

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

8.7.3  Consequences of twin pregnancy

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

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

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

Other complications include the following:

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

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

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

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

8.8  Management of women with malpresentation or multiple pregnancy

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

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

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

Summary of Study Session 8

In Study Session 8, you learned that:

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

Self-Assessment Questions (SAQs) for Study Session 8

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

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

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

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

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

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

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

E  Hypoxia — the baby gets too much oxygen.

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

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

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

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

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

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

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

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

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

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

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

SAQ 8.2 (tests Learning Outcomes 8.1 and 8.2)

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

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

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

SAQ 8.3 (tests Learning Outcomes 8.3 and 8.5)

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

SAQ 8.4 (tests Learning Outcomes 8.4 and 8.5)

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

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

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• v.12(2); 2017 Jun

Mode of Delivery in Stillbirth

Natalia florina buinoiu.

”Filantropia” Clinical Hospital, Bucharest, Romania

Sabrina Ioana STOICA

Anca panaitescu.

Department of Obstetrics and Gynecology, “Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania

Gheorghe PELTECU

Nicolae gica.

In Romania, a national statistics report on the mode of delivery in pregnancies that ends in stillbirths has never been conducted. Thus, we decided to analyze the incidence of cesarean section versus vaginal delivery rate over a 10-year period in Filantropia Clinical Hospital of Bucharest.

Materials and Methods:

We conducted a retrospective analysis over a period of 10 years from January 2005 to December 2015. Maternal age, parity, social status, place of origin, educational level, gestational age, fetal presentation and fetal sex were studied in order to see if there were a scientific correlation with death in utero.

Between 2005 and 2015, Filantropia Clinical Hospital had a total of 31676 births after the 28th week of gestation. During this time period, 174 (0.55%) stillbirths were registered. The overall number of cesarean sections in live-births was 13199 (41.7%) and the rate of cesarean sections calculated for the stillbirth was 17.24% (30/174).

Conclusion:

Our study revealed that the rate of cesarean sections in stillbirth had a dramatic decrease based on the adoption of guidelines reflecting evidence based medicine. The vast majority of pregnancies included in our study did not undergo standard perinatal tests and screenings that ensure a healthy and safe delivery, as it is a known fact that many causes of perinatal deaths can be prevented by health care access and perinatal regular visits. We suggest that a proper follow up in the last trimester and easy access to health care facilities can lower the incidence of stillbirths in Romania.

Keywords: stillbirth, cesarean section, vaginal birth, high-risk pregnancies

Despite the major interest in preventing intrauterine fetal death in the last decades, a common definition of stillbirth is yet to be accepted worldwide. Definitions vary amongst countries according to their national legislation. In the United States, the American College of Obstetricians and Gynecologists states that each fetal death of 350 grams or more, or if the weight is unknown, with at least 20 weeks of gestation completed shall be reported to the National Center of Health Statistics (1). The World Health Organization (WHO) recommends the following definition of intrauterine death as an international consensus: a baby born with no signs of life, at or after 28 weeks of gestation (2).

In Romania, any baby delivered at the 24th week of gestation with signs of life is registered as a living newborn and stillbirths is defined in accordance to the WHO criteria (3).

When an intrauterine fetal death is diagnosed, termination of pregnancy is recommended. We strongly endorse vaginal birth in these cases rather than cesarean section (CS), which is still popular among Romanian obstetricians. The surgical procedure (cesarean section) has high risks compared to any other abortion procedure. It could adversely affect the future fertility of the patient. However, CS should be performed if all medical procedures have failed or the situation requires it (fetal transverse lie with prior CS or placenta accreta/increta). Individualized clinical judgment of each case can lead to either expecting a spontaneous onset of labor, which usually occurs within 14 days after the diagnosis (4), or induction of labor can be performed using local prostaglandins or systemic oxytocin (5).

The aim of this study was to analyze the mode of delivery in pregnancies ending with stillbirths. We also tried to find if there were any patterns in stillbirth pregnancies and how the decision to deliver the patient was founded.

MATERIALS AND METHODS

We conducted a retrospective analysis over a period of 10 years from January 2005 to December 2015 in Filantropia Clinical Hospital, a third level teaching hospital. During this period were registered 31676 births over the 28th week gestation, 174 of which were diagnosed as antepartum deaths. The diagnosis was established by the absence of fetal heartbeat during the ultrasound examination performed immediately upon the patient’s arrival. Gestational age was established taking into account the patients last menstrual period as well as ultrasound measurements of the fetus, since the majority of the patients were at the first presentation at an obstetrician.

We tried to notice the mode of delivery in stillbirths, the indications for cesarean section delivery and if there was a higher frequency of intrauterine fetal death in correlation with socioeconomic status, maternal age at conception, parity, gestational age and fetal gender.

Between 2005 and 2015, 31676 births were registered in our database after the 28th week of gestation, of which 174 were stillbirths (including 12 tween pregnancies from which only three had both fetuses nonviable). The overall number of CS performed on live births was 13199 (41.7%) and 17.24% (30/174) represented the ratio calculated for the stillbirth group (Table 1). During the study we noticed an increased frequency amongst cesarean delivery in live births with the highest peak in 2010 when the rate of CS was 49.64% and the lowest in 2005, 32.70%. In 2015, the rate of CS reached 41.67%. Meanwhile, we have noticed a sharp decrease of cesarean sections in stillbirth group. Despite the high peak in 2008 when almost half of the stillbirth pregnancies finalized by cesarean section, in 2015 the rate of vaginal delivery was 90%.

The incidence of stillbirth in our study was found to be 0.55% (174 stillbirths) and in only 30 cases (17.24%) (Table 2) it was decided to perform a cesarean section in order to deliver the dead fetus. The indications for CS were gestational hypertension/preeclampsia (16 cases), placental abruption with massive bleeding (12 cases), twin pregnancies with one fetus living and one death associated with breech/transverse lie and previous cesarean section (8 cases), breech presentation (1 case), placenta praevia (1 case), leiomyoma praevia (1 case).

The majority of stillbirths were found in women in the age group of 25-30 years and not in the extreme groups as we expected (Table 3) (6). Almost half of them were at first delivery (P 1) (52.87%) followed by second delivery (P2) in 29.31% of cases (7) (Table 4). Thus, parity was not associated with a higher risk of stillbirth, as it was reported in a study from Nepal (8).

Despite the observation that most women came from urban areas (71.83%), their socioeconomic level and medical education was lower than expected as that was their first presentation to a doctor during the current pregnancy, despite the fact that access to medical facilities is available and free of charge for all pregnant patients (Table 5).

Preterm pregnancies prevailed within the study group (71.26%) and only few post-term pregnancies were noted (10.34%) (Table 6).

About 19% (Table 7) unviable fetuses were in abnormal presentations and 18 (60%) fetuses had major congenital abnormalities including corpus callosum agenesis, spina bifida, ventricolomegaly, anencefaly, hidrocephalus, fetal hydrops, fetal ascites, fetal anasarca and bilateral renal agenesis. Only few (12 cases) were noticed to have intrauterine growth restriction which was associated with gestational hypertension.

The male gender was found to have a higher incidence (55.17%) comparing to the female gender (44.83%) (Table 8) (9).

Cesarean delivery is a common surgical procedure in Romania. Romanian obstetricians easily adopt CS delivery as the gold standard in order to finalize a pregnancy. Still, many patients with previous CS become adequate candidates for another cesarean delivery, even those with stillbirth in their medical history. In addition, stillbirth has a physical, emotional, psychiatric and social effect on parents, on their relatives and sometimes even on the obstetrician who decides to adopt CS as mode of delivery.

According to the management protocol of late intrauterine fetal death and stillbirth (October 2010) of the Royal College of Obstetricians and Gynecologists (RCOG) vaginal birth is the recommended mode of delivery for most women, but caesarean birth will need to be considered for some patients. They recommend a combination of mifepristone and a prostaglandin as first-line intervention for labour induction (10).

CS has very limited indications in stillbirth, because its complications could affect the future fertility of the patient. Implementing evidence based medicine guidelines, the incidence of CS has had a dramatic decrease in our institution. According to ROCG, the management of late intrauterine fetal death and stillbirth of in patients with a single lower segment scar, induction of labour should be conducted with prostaglandins with minimal risks. Women with two previous lower segment scars should be advised regarding the risk of induction with prostaglandin , which is higher than for women with a single previous CS. In patients with more than two lower segment scars or atypical scars, the risks of labour induction is unknown (10).

In our clinic, in order to avoid further complications in upcoming pregnancies, women who were rhesus D (RhD)-negative received anti-RhD gammaglobulin after delivery despite the baby’s blood result, as most of time blood samples were not available. Most of the antepartum conditions we managed to diagnose were predictable and included: congenital fetal malformations, gestational hypertension/ pre-eclampsia and antepartum haemorrhage. However, in order to establish a transplacental infection, patients were referred to an Infectious Disease Department for further investigations.

We strongly recommend vaginal delivery rather than cesarean section in stillbirths. After detailed discussions with patients, we managed to avoid cesarean delivery on request. Despite that spontaneous onset of labour can occur within 14 days since diagnosis, we did not adopt an expectative management protocol. We proceeded with labour induction immediately after fetal heart beat was not recorded. The method of choice was the mechanical method – introducing a transcervical balloon catheter – and secondly we used intravenous oxytocin due to the absence of an approved prostaglandin in Romania. Previous cesarean section did not lead to another cesarean section in our clinic, as it is known that double scared uterus leads to abnormal placental adhesions. We used oxytocin augmentation in order to achieve vaginal birth after CS (VBAC) without any uterine rupture recorded. Heparin thromboprophylaxis has been adjusted to the individual clinical and biochemical profile; otherwise it was not administered routinely. Antibiotic prophylaxis is not recommended, unless signs of sepsis are noted. All patients received dopamine agonists in order to suppress the lactation.

The patients were discharged as soon as the clinical situation allowed us, in order to achieve a full recovery in a familiar environment among family members and to lower the risk to develop postpartum depression.

Our study reveals that the majority of stillbirths were found in women in the age group of 25-30 years and not in the extreme groups of age. Parity was not associated with a higher risk of stillbirth. Furthermore, most of the pregnancies were preterm <37 weeks of gestation and we noticed a higher incidence in intrauterine fetal death in male fetuses rather than in females.

The incidence of stillbirth in Romania remains high, regardless the efforts to provide easy access to medical health facilities despite the patient’s place of residence and the socio-economic status. We noticed that more than half of the fetuses had major congenital abnormalities and mothers were not examined by a doctor during their pregnancy, which leads us to the idea that there is a major educational gap regarding the necessity of antenatal care attendance. Some of the underlying factors responsible for intrauterine fetal death could be identified during pregnancy and measures should be taken to better manage the outcome, if the mother has routine checkups with her obstetrician.

Regarding the way to deliver a stillbirth, we strongly recommend vaginal delivery after induction of labor for all pregnancies in the second trimester. Cesarean section delivery is a high risk procedure, which carries a greater risk than any other medical procedure; therefore, it should not be used as a first line procedure. Its indications are very limited because its complications could affect the future fertility of the patient. By implementing evidence based medicine guidelines, the incidence of CS had a dramatic decrease in our institution. In conclusion, we strongly recommend that medical education should be introduced in school curriculum, family planning centers should function in rural areas and general practitioners should raise awareness among the young female population regarding the correct approach towards pregnancy, in order to reduce the incidence of intrauterine fetal death.

Conflict of interests: none declared.

Financial support: none declared.

Characteristics of patient’s deliveries between 2005 and 2015

Distribution of stillbirths according to the mode of delivery

Distribution of stillbirths according to maternal age

Distribution of stillbirths according to parity

Distribution of stillbirth according to environmental origin

Distribution of stillbirth according gestational age

Distribution of stillbirths according to presentation

Distribution of stillbirths according to fetal sex

Contributor Information

Anca PANAITESCU, ”Filantropia” Clinical Hospital, Bucharest, Romania. Department of Obstetrics and Gynecology, “Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania.

Gheorghe PELTECU, ”Filantropia” Clinical Hospital, Bucharest, Romania. Department of Obstetrics and Gynecology, “Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania.

• Centers for Disease Control and Prevention/ National Center for Health Statistics - Model State Vital. Statistics Act and Regulations. 1994; 10 :94–1115. [ Google Scholar ]
• World Health Organization   Kidney International. 2016;   [ Google Scholar ]
•   - ORDIN nr. 359 din 4 aprilie 2012 privind criteriile de înregistrare si declarare a nou-nascutului . htt p://www.monitoruljuridic.ro/act/ ordin-nr-359-din-4-aprilie-2012. 2012;   : – . [ Google Scholar ]
• U Reddy Maternal - Fetal Evidence Based Guidelines. Maternal-Fetal Evidence Based Guidelines. - 2nd ed. London, UK. 2012;   [ Google Scholar ]
• Canterino J, et al. - Maternal age and risk of fetal death in singleton gestations: USA, 1995-2000. J Matern Fetal Neonatal Med. 2004; 3 :193–197. [ PubMed ] [ Google Scholar ]
• Saurabh K, Patel K. - Study of the risk factors contributing to stillbirths in Central India.   2015; 3 :13–16. [ Google Scholar ]
• Ashish KV, Johan W, Uwe Ewald, et al. - Risk factors for antepartum stillbirth: a case-control study in Nepal. BMC Pregnancy and Childbirth. 2015;   :15–146. [ PMC free article ] [ PubMed ] [ Google Scholar ]
• Debapriya G, Trevor C and Fiona M. - Elevated risk of stillbirth in males: systematic review and meta-analysis of more than 30 million births. . BMC Medicine. 2014; 6 :12–220. [ PMC free article ] [ PubMed ] [ Google Scholar ]
• Siassakos D, Fox R, Draycott T, Winter RM. - Management of late intrauterine fetal death and stillbirth. Royal College of Obstetricians and Gynecologists. 2010;   :55–13. [ Google Scholar ]

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States push ‘fetal personhood’ bills despite outrage at Alabama IVF ruling

Lawmakers in more than a dozen states have considered efforts to give legal rights and protections to embryos and fetuses

Lawmakers in more than a dozen states have considered efforts to endow embryos or fetuses with legal rights and protections since the start of the year, and at least three states have advanced such “fetal personhood” legislation since February, when an Alabama supreme court decision ruling that frozen embryos are “extrauterine children” unleashed national outrage.

The Alabama state legislature responded to the repercussions of that ruling – which led several of the state’s in vitro fertilization (IVF) providers to halt their work – by passing a bill to protect providers’ ability to offer that treatment. Yet, just hours after the legislature passed those protections, Republicans in the Iowa statehouse passed a fetal personhood bill that amends state law to criminalize causing the “death of an unborn person”.

An “unborn person”, according to the Iowa bill, is “an individual organism of the species homo sapiens from fertilization to live birth”. Such a definition would include frozen embryos, which are eggs that have been fertilized by sperm. If passed by the Republicans who control the Iowa state senate, the bill could endanger IVF access in the state. But because the language of the bill is so broad, prosecutors may also try to apply it to a wide range of circumstances. Causing the “death of an unborn person” intentionally through acts like murder, assault or sexual abuse would be a Class A felony, punishable by a life sentence. Doing so unintentionally would be a Class B felony. The bill even specifies that unintentionally causing “the death of an unborn person while drag racing” would be a Class D felony.

State legislators have also recently pushed fetal personhood language in other, less conspicuous areas of law. In early March, the Kentucky state senate passed a bill to establish the right to demand child support for fetuses; that bill has passed to the statehouse, which, like the senate, is dominated by a Republican supermajority.

That same week, the Republican-controlled Utah state legislature sent the governor there a bill that would allow fetuses to seek legal restitution if the fetus’s parent has been killed or injured.

“Fetal personhood exists in some form or fashion in pretty much every state,” said Dana Sussman, deputy executive director of Pregnancy Justice, an advocacy organization supporting people who face criminalization over their pregnancies. She warned of the sweeping effects of such language even in what seem like narrow contexts. “We have to grapple with the implications, because when it’s in law in one area … we see the creep into other areas of law. Judges will say: ‘Well, it’s a person in this context. So why isn’t it a person in that context?’”

As of 2022, at least 11 states – including Alabama – have what Pregnancy Justice identified as “extremely broad personhood language that could be read to affect all state laws, civil and criminal”, according to a brief by the organization. “Those are the ones that really have the power in their language itself to increase criminalization of pregnant people, to threaten IVF, to threaten forms of contraception and obviously to ban abortion,” Sussman said.

Much opposition to abortion springs from the belief that life begins at conception, and the fetal personhood movement is a natural outgrowth of anti-abortion organizing. But for decades, Roe v Wade curbed the movement’s influence, allowing mainstream Republicans to reap the votes of anti-abortion activists and fetal personhood proponents without having to reckon with the real-world consequences of their policies. Now that the US supreme court has overturned Roe, these seemingly fringe movements are moving into the mainstream and their policies’ consequences are materializing – to many Republicans’ surprise and voters’ outrage .

Fetal personhood has seeped into contexts that may surprise even the people who support it. In Missouri, which has broad fetal personhood language on the books, people convicted of child molestation and statutory rape have argued that that language means courts should base an underage victim’s age not on their date of birth, but on the date of their conception – making them nine months older.

Mary Ziegler, a professor at the University of California at Davis who studies the legal history of reproduction, said many people on the right have never been forced to confront the consequences of fetal personhood’s sweeping impact.

“That’s really what you’re seeing play out in real time,” said Ziegler, who is writing a book about fetal personhood. “Republicans and frankly even people in the anti-abortion movement never really had to answer any of these questions before.”

Several of the bills now under consideration in state legislatures were originally introduced in 2023 but could still become law, according to the Guttmacher Institute, which shared a tally of fetal personhood bills with the Guardian. However, since the Alabama IVF ruling in mid-February – arguably the highest-profile illustration to date of the practical effects of fetal personhood language – related bills have died in Florida, West Virginia and Colorado.

At least 38 states also have “fetal homicide” laws, which establish that homicide charges can be brought for the loss of a pregnancy. Although the mainstream anti-abortion movement contends that it does not want to punish women for their pregnancy outcomes, women in states such as California, Indiana and Texas have faced feticide and murder charges over their own pregnancy losses.

Pregnancy Justice has also uncovered more than 600 cases, filed between 2006 and 2022, where people in Alabama faced criminal consequences over their pregnancies. That’s more than any other state in the country.

In 2018, Alabama became the first state in the country to enshrine a fetal personhood clause into its state constitution, after voters backed a measure to recognize “the rights of the unborn child”, including the right to life. The Alabama supreme court ruling in February cited that clause in the state constitution as a justification for its judgment.

For fetal personhood activists, the ultimate goal is to convince the US supreme court to take up a fetal personhood case, according to Ziegler. Many activists want the court to rule that the 14th amendment, with its guarantees of due process of law and equal protection, covers embryos and fetuses. Such a ruling would establish fetal personhood on a federal scale.

“The idea is to have as many state laws and as many state decisions as you can get saying that a fetus is a person in various contexts, so it becomes more and more incongruous that a fetus is not a person in the context of constitutional law,” Ziegler said. “To say to the court: ‘Don’t you want to harmonize constitutional law with all these other areas of the law? Don’t you see how the states are clamoring for this, the way they were clamoring for the overruling of Roe?’

“It’s part of the very long game,” she said.

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PATHOGENESIS AND RISK FACTORS

● The fetus does not fully occupy the pelvis, thus allowing a fetal extremity room to prolapse. Predisposing factors include early gestational age, multiple gestation, polyhydramnios, or a large maternal pelvis relative to fetal size [ 2,3 ].

● Membrane rupture occurs when the presenting part is still high, which allows flow of amniotic fluid to carry a fetal extremity, umbilical cord, or both toward the birth canal.

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Why are antiabortion activists going after sex education?

The abortion wars are opening up a new front in a classroom near you..

The fight for fetal personhood made headlines last month when the Alabama Supreme Court held that embryos counted as persons under the state’s wrongful death of a minor act. For a short time, the decision not only led many providers in the state to pause IVF services but also shone a spotlight on the antiabortion movement’s goal to bestow legal rights on fetuses more broadly.

I’ve argued previously that the battle for fetal personhood is about much more than abortion. Indeed, antiabortion activists are opening up a surprising new front: the future of sex education. Several states are considering legislation that would require students to learn about fetal development using an animation called “Meet Baby Olivia” created by a prominent antiabortion group, Live Action, or else by showing a similar presentation covering the stages of fetal development.

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Live Action developed “Olivia” as a tool to convince Americans that life begins at fertilization and to “defend [Olivia’s] constitutionally protected right to life.” The medical community has widely criticized the animation for misleading claims, like stating that the fetus named Olivia was “playing” at 11 weeks or that survival outside the womb was possible at 20 weeks.

To the extent these proposals are successful, sex education won’t be about sex. It will be about fetal development — and fetal rights.

Last year, Live Action presented the animation to multiple gatherings of state lawmakers, which appears to have resulted in an appetite among some for including it in school curricula. But rather than defining the film as part of a religion or life sciences curriculum, state lawmakers have proposed to reinvent their sex education classes. North Dakota became the first state in the nation to pass a bill requiring schools to either show films like “Olivia” or omit sex education programs altogether.

Administrative guidance issued to schools in North Dakota refers to the Live Action film by name. Similar bills have also been introduced in West Virginia, Iowa, Kentucky, and Missouri.

Social conservatives have turned sex education into a battlefield before. In the 1960s and 1970s, when progressive advocates first urged schools to adopt sex ed programs to reduce unplanned pregnancy and sexually transmitted infection, organizations like the Moral Majority — a leading group among the Christian right in the 1980s — opposed the move . Later, following the AIDS epidemic, many of these groups moderated their positions to embrace abstinence-only sex education, an approach that still shapes how reproductive and sexual health is taught in public schools in several states , including North Dakota.

Abortion opponents, on the other hand, have not historically tried to influence sex education programs directly. They have spread fetal images and publicized movies like “The Silent Scream,” a 1980s film that claimed to document an abortion in real time but framed abortion as an issue involving reproduction, not sex.

So why has the antiabortion movement suddenly grabbed onto sex education? The answer has everything to do with Roe v. Wade’s reversal, which created two separate problems for the antiabortion movement. First, it forced abortion opponents to identify a new rallying cry — something to unite a fragmented movement that has often embraced unpopular positions. Without a new goal, the antiabortion movement risked losing donors and seeing grassroots activists drift away to other conservative causes. Second, the Supreme Court decision unleashed a backlash that has made conservative lawmakers more gun-shy about public anger.

As far as a new goal was concerned, the answer for the antiabortion movement was easy: fetal personhood. The movement had organized in the 1960s to fight for fetal personhood, which is the idea that a fetus counts as a person under the 14th Amendment of the Constitution and that laws allowing abortions violate that person’s constitutional rights .

That’s where the “ Baby Olivia” bills come in. Lawmakers can require schools either to abandon sex education programs or to show films like “ Baby Olivia,” whose primary aim, according to Live Action’s founder Lila Rose, is to convince viewers of “the humanity of children in the womb” — and the unacceptability of “the barbaric procedures abortionists use to kill them.” Such bills can more easily fly under the radar — they aren’t new bans on abortion or in vitro fertilization — but they can still help groups like Live Action recruit new members and build a legal case for the idea that a fetus has constitutional rights.

We’ve seen wars over sex education before, but supporters of fetal personhood think they have found a way to win in more conservative states. For example, some school districts in North Dakota might choose to eliminate sex education curricula rather than show “Baby Olivia,” but many will simply show the film or one like it. And rather than learning much (or anything) about safe sex, a new generation of students will be invited to join the war for fetal rights.

Mary Ziegler is a professor of law at the University of California, Davis. Her latest book is “ Roe: The History of a National Obsession .”

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How 'fetal personhood' in Alabama's IVF ruling evolved from fringe to mainstream

Odette Yousef

Alabama's state capitol in Montgomery, Ala. earlier this year. Andi Rice/Bloomberg via Getty Images hide caption

Alabama's state capitol in Montgomery, Ala. earlier this year.

The Alabama Supreme Court's decision that frozen embryos have the same rights as children came as a surprise even to many who oppose abortion rights. But for researchers and activists who have long tracked narratives at the most extreme end of the anti-abortion movement, this legal determination was inevitable.

They say it shows how, even as the pro-abortion rights movement focuses on preserving legal access to abortion and contraception, other laws that codify the once-fringe notion of "legal personhood" may more immediately underpin decisions that could drastically curtail reproductive rights.

"The movement that's referred to as 'personhood,' to indicate that life begins at conception, was always going here," said Alex DiBranco, executive director and co-founder of the Institute for Research on Male Supremacism.

DiBranco said that while IVF may be popular among Americans on both sides of the political spectrum, hardline conservative organizations like the Heritage Foundation and Live Action have long villainized the IVF industry. Often referring to it as the "big fertility" industrial complex, they characterize the sector as predatory and profit-driven.

"They talk a lot about the idea that it's eugenics, that it's really more about designer babies than actually supporting women or other people who have fertility needs," DiBranco said.

Alabama justice's ties with far-right Christian movement raise concern

At its most extreme, reproductive rights researchers and advocates warn that states where fetal personhood is established could even see courts citing those laws in criminal cases where pregnant people are concerned. They say the door to this application was opened decades ago when the American public succumbed to widespread hysteria over so-called "crack babies."

A moral panic normalizes a fringe idea

In 1973, when the Supreme Court issued its decision on Roe v. Wade , the notion that fetuses or embryos were full rights-bearing humans under the law was not widely popular.

"Immediately in the days after that decision, there were proposals to codify some form of fetal personhood," said Dana Sussman, deputy executive director at Pregnancy Justice, an organization that provides legal defense services to pregnant people in civil and criminal cases. "It did not gain traction until ... the late 80s and early 90s. And that was when the war on drugs was on a collision course with the war on abortion."

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The science of ivf: what to know about alabama's 'extrauterine children' ruling.

Sussman and others say that it was the moral panic over so-called "crack babies" that took the idea of fetal personhood from fringe to mainstream. At the time, there were widespread fears that prenatal use of crack cocaine could lead to children who might grow to have a number of problems. The narrative contained classic moral panic tropes: children in utero as helpless victim; and a scapegoat that garnered little sympathy within the American public at the time, namely poor, African-American women who used drugs.

Several states passed laws that allowed women to be charged with criminal child abuse for exposing their fetuses to illicit substances during pregnancy. These resulted in hundreds of women being jailed in connection with their pregnancies. Just as significantly, the laws also entrenched the concept of fetal personhood into state criminal codes.

"It was a political opportunity for the anti-abortion movement, through the fears of and the hysteria surrounding the 'crack baby' epidemic," said Sussman.

In the years since then, studies show that children born to mothers who used crack cocaine while pregnant carry no significant difference in their life outcomes when compared with other children. Nonetheless, the exploitation of the fear at the time was potent. It opened the door to charging women with crimes against their own pregnancies. It also shifted popular opinion on the concept of fetal personhood. A 2022 survey by the Pew Research Center found that 56% of Americans believe that "human life begins at conception, so a fetus is a person with rights."

A wave of fetal personhood bills

In Alabama, Sussman said the path toward the IVF decision had been cleared at least a decade earlier. In 2013, the state's Supreme Court ruled that fetuses are considered children in criminal cases concerning prenatal exposure to controlled substances.

"So this has been the creep, and it started primarily in criminal law," said Sussman. "And it has extended to the law that was at issue in the Alabama Supreme Court [on frozen embryos] ... which is a civil law that now impacts IVF and fetal personhood."

How states giving rights to fetuses could set up a national case on abortion

Those who have followed these developments closely say this cascade of small shifts has been tragic to watch.

"I wish we cared when it was impoverished women who were being locked up," said Grace Howard, associate professor of Justice Studies at San Jose State University.

"I'm glad that people are outraged about [the IVF ruling]. They should be outraged about this," she said. "But damn, if they had been this pissed off a decade ago, I don't think that we would be where we are right now because it would have stopped this creep from happening."

According to Pregnancy Justice , at least 11 states currently have laws broadly defining fetal personhood. In those states, these definitions could interplay broadly with civil and criminal codes. But it notes that all states have case law or statutes that, in some area, designate fetuses as a "person," "minor" or "child."

"There are personhood laws that exist in multiple states around the country that are not being effectuated to their full extent," said Sussman. "The concern that we have here is that, whether it's prosecutors [or] whether it's litigants, will start to use those laws to criminalize self managing abortion, criminalize pregnancy loss, criminalize behavior during pregnancy, go after IVF in the way that we saw in this civil case or criminally, too. ... And so that is sort of the sleeping threat that lingers in a lot of these states."

According to the Center for Reproductive Rights, 13 states currently have personhood bills under consideration, from Alaska to Illinois to Massachusetts. While much of the concern currently centers on how these may be used in relation to IVF services, Howard warns that the ramifications could extend far beyond, to the people who are, themselves, pregnant.

"The way I see it, once any element of this is criminalized or once the fetus is defined as a person in any area of law, criminalization is the next step and it is not hard to do," she said.