Typically, a baby is born in a head-first anterior presentation. Anterior means the back of the baby’s head is turned towards the mothers front side so the baby is facing the mother’s spine. This is known as the cephalic or vertex position and allows the baby to pass through the birth canal without injury to the head or limbs. In the cephalic position, the baby’s head is at the lower part of the abdomen prior to childbirth. However, some babies present differently before delivery. These abnormal presentations may place the baby at risk of experiencing umbilical cord problems and/or a birth trauma and include the following:
1) Compound Presentation – means there are multiple presenting parts which means that the baby’s head and an arm come out at the same time. This can occur with twins where the head of the first twin presents with the extremity of the second twin. Compound presentations can be detected via ultrasound before the mother’s water breaks. During labor, compound presentation is identified as an irregular finding during a cervical examination. If compound presentation continues, it is likely to cause dystocia (the baby becoming stuck in the birth canal), which is also a medical emergency. Often, the safest way to deliver a baby with compound presentation is C-section, because complications like dystocia and cord prolapse carry risks of severe adverse outcomes, including cerebral palsy, intellectual and developmental disabilities, and hypoxic-ischemic encephalopathy (HIE).
2) Limb Presentation – means that the part of the baby’s body that emerges first is an arm or a leg. Babies with limb presentation cannot be delivered safely via vaginal delivery and must be delivered quickly by emergency C-section. Limb presentation poses a large risk for dystocia (the baby getting stuck on the mother’s pelvis).
3) Occipitoposterior (OP) Position – about 1 out of 19 babies present in a posterior position rather than an anterior position. In OP position, the baby is head-first but with the back part of the baby’s head facing the mother’s spine. The OP position increases the baby’s risk of experiencing prolonged labor, prolapsed umbilical cord, and use of delivery instruments, such as forceps and vacuum extractors. These conditions can cause brain bleeds, a lack of oxygen to the brain, and birth asphyxia.
When OP position is present, if a manual rotation cannot be quickly and effectively performed in the face of fetal distress, the baby should be delivered via C-section. A C-section can help prevent oxygen deprivation caused by prolonged labor, umbilical cord prolapse, or forceps and vacuum extractor use.
4) Breech Presentation – occurs when a baby’s buttocks or legs are positioned to descend the birth canal first. Breech positions are dangerous because when vaginal delivery is attempted, a baby is at increased risk for prolapsed umbilical cord, traumatic head injury, spinal cord fracture, fatality, and other serious problems with labor.
There are four types of breech presentation:
footling breech presentation – one or both feet enter the birth canal first, with the buttocks at a higher position than the feet.
kneeling breech presentation – one or both legs extended at the hips and flexed at the knees.
frank breech presentation – buttocks present first, the legs are flexed at the hip and extended at the knees, and the feet are near the ears.
complete breech presentation – hips and knees are flexed so that the baby is sitting cross-legged, with the feet beside the buttocks.
When a baby is in breech position, physicians may try to maneuver the baby into a head-first position. This should only be attempted if fetal heart tracings are normal (the baby is not in distress) and the baby is being closely monitored.
In most circumstances, vaginal birth should not be attempted and many experts recommend C-section delivery for all types of breech positions because it is the safest method of delivery and it helps avoid birth injuries.
5) Face Presentation – means that the face is the presenting part of the baby. In this position, the baby’s neck is deflexed (extended backward) so that the back of the head touches the baby’s back. This prevents head engagement and descent of the baby through the birth canal. In some cases of face presentation, the trauma of a vaginal delivery causes face deformation and fluid build-up (edema) in the face and upper airway, which often means the baby will need a breathing tube placed in the airway to maintain airway patency and assist breathing.
There are three types of face presentation:
Mentum anterior (MA) – the chin is facing the front of the mother.
Mentum posterior (MP) – the chin is facing the mother’s back, pointing down towards her buttocks in mentum posterior position. In this position, the baby’s head, neck, and shoulders enter the pelvis at the same time, and the pelvis is usually not large enough to accommodate this. Also, an open fetal mouth can push against the bone (sacrum) at the upper and back part of the pelvis, which also can prevent descent of the baby through the birth canal.
Mentum transverse (MT) – the chin is facing the side of the birth canal in this position.
Trauma is very common during vaginal delivery of a baby in face presentation, so parents must be warned that their baby may be bruised and that a C-section is available to avoid this trauma.
Babies presenting face-first can sometimes be delivered vaginally, as long as the baby is in MA position, but normally should be delivered by C-section.
6) Brow Presentation – is similar to face presentation, but the baby’s neck is less extended. A baby in brow presentation has the chin untucked, and the neck is extended slightly backward. As the term “brow presentation” suggests, the brow (forehead) is the part that is situated to go through the pelvis first. Vaginal delivery can be difficult or impossible with brow presentation, because the diameter of the presenting part of the head may be too big to safely fit through the pelvis
7) Shoulder Presentation – also known as “transverse lie” occurs when the arm, shoulder or trunk of the baby enter the birth canal first. When a baby is in a transverse lie position during labor, C-section is almost always used as the delivery method. Mothers who have polyhydramnios (too much amniotic fluid), are pregnant with more than one baby, have placenta previa, or have a baby with intrauterine growth restriction (IUGR) are more likely to have a baby in the transverse lie position. Once the membranes rupture, there is an increased risk of umbilical cord prolapse in this position; thus, a C-section should ideally be performed before the membranes break. Failure to quickly deliver the baby by C-section when transverse lie presentation is present can cause severe birth asphyxia due to cord compression and trauma to the baby. This can cause hypoxic-ischemic encephalopathy (HIE), seizures, permanent brain damage, and cerebral palsy.
If you believe your child’s birth injury was caused by a health care provider’s negligence, you and your child may a medical malpractice claim. Birth injury cases are complex and involve multiple health care providers, including obstetricians, gynecologists, neonatologists, labor and delivery nurses, and other medical professionals. All of these health care providers have an obligation to adhere to a standard of care during the labor and delivery process. The standard of care refers to the steps that another medical professional in the same or similar specialty would take under similar circumstances.
If your child has been harmed by the carelessness of a medical professional during the labor and delivery process, the Thistle Law Firm is experienced at handling these claims. They can help you understand your legal options and answer your questions at 215-525-6824.