When a Baby is in the Wrong Position or Wrong Direction before Delivery
Two important considerations for a woman nearing the end of her pregnancy are the presentation and position of her baby. Fundamentally, the way that the fetus enters the birth canal and the direction that the fetus faces have a significant effect on labor and delivery. Abnormal position or presentation may mean that the pregnant woman is in for a long and difficult vaginal delivery or a C-section delivery. Regardless of the situation, doctors and healthcare providers must be at the ready to act whenever necessary. Even before birth occurs, proper assessments, planning, and a prepared action plan that can be modified if circumstances change are critical for the mother’s and baby’s protection.
Fetal Presentation vs. Position
First and foremost, it is important to understand the distinction between presentation and position when it comes to childbirth. A fetus exits the birth canal with one part of the body or another. This is known as the presentation. On the other hand, the direction in which the fetus is facing in the womb is its position. For instance, is the fetus facing toward the front or the mother’s body or her back? Both of these are key when determining the appropriate course of action prior to and during labor and delivery, as well as the right delivery method to protect the mother’s and child’s safety.
What is Considered Normal Position and Presentation and what is Abnormal?
The safest position for a fetus ready to deliver is facing the mother’s front of the body and the safest presentation is headfirst through the birth canal. When a fetus is headed down the birth canal feet, face, or shoulders first, the presentation is considered abnormal. Likewise, if the fetus is facing the mother’s back, the fetus’s position is considered abnormal. The least difficult delivery position and presentation is facing the mother’s back and proceeding down the birth canal headfirst, with the highest point of the head, or vertex, leading down the canal. Ideally, the fetus is also situated facing slightly right or left, with a tucked chin and arms crossing the chest. All other positions and presentations are considered abnormal.
When the Baby is Face Forward
When facing the wrong direction, the fetus’s face may be forced forward as it moves through the curvature of the mother’s pelvis and the vaginal canal. Thus, the headfirst presentation may be right, but the face forward position creates enhanced tension and pressure on the fetus’s stretched out neck, with the chin jutting far forward. Known as occiput posterior, this position typically requires instrument-assisted delivery with forceps or vacuum extractor, or surgical intervention by C-section. If a baby cannot be safely delivered with birth-assistance tools, a cesarean may be the only way to birth the fetus in this position.
Still another unsafe situation occurs when the fetus’s brow is angled first down the birth canal. In these cases, the neck can also be stretched like face forward presentation, as the chin is pressed upward. This may be the result of a misshapen pelvis, weak uterine muscles, multiple prior pregnancies, or polyhydramnios.
Meaning of Breech Presentation
Another abnormal presentation, breech births, are buttocks or feet first deliveries. In early pregnancy, a fetus is breech because the head is larger than the rest of the body and fits better into the largest and topmost part of the uterus. As the fetus’s body fills out in later pregnancy and in preparation for birth, it should right itself facing downward.
A breech birth increases the likelihood of serious injuries. If not addressed properly, the baby may suffer harm on the way out of the birth canal, but also before or after the baby is born. The delivery goes quickly and smoothly most often when the fetus’s head, the largest part of its body, makes its way through the birth canal first. As the birth canal widens to accommodate the size of the head, then the smaller remainder of the body can seamlessly follow under ordinary circumstances. Conversely, the larger head can become wedged in the birth canal when the smaller buttocks and feet go first. This situation is highly dangerous, as it may create enhanced pressure on the umbilical cord when the baby’s head gets stuck in the birth canal. A decrease in oxygen flow soon follows, placing the infant’s brain and their very life in jeopardy, as an oxygen-deprived brain can lead to brain damage and even fatality.
If the Shoulder gets Stuck behind the Pelvic Bone
Even if the fetus is in the right position and presentation, a baby’s shoulder can get stuck against the pelvic bone while traveling through the birth canal. This condition is called shoulder dystocia. While the baby’s head is delivering, the stuck shoulder then stretches the neck, risking major injury to the child. Not only that, but the delivery is stalled, and the fetus’s oxygen supply may be cut off, a common cause of brain damage.
Risk Factors for Abnormal Delivery Presentation
Although causes for a baby’s abnormal position or presentation in the womb are often unknown, some risk factors for abnormal presentation or position include:
- Too little or too much amniotic fluid
- A misshapen pelvis
- Uterine tumors
- Weak uterine muscles
- Placenta previa
- Pregnancy involving multiples (twins, triplets, or more)
Notably, some types of delivery presentations have particular, identified possible causes. For instance, beech presentation has been associated with fetal birth defects, premature labor, and abnormalities affecting the uterus, including fibroids. Breech presentation may likewise be caused by multiple fetuses, excess amniotic fluid (polyhydramnios), water on the baby’s brain (hydrocephalus), and placenta previa. In addition, a presenting with a transverse lie may be caused by weak uterine muscles, an abnormal uterus or narrow pelvis. Like other abnormal presentations, preterm labor, polyhydramnios, prior pregnancies, and placenta previa may also play a role in shoulder presentation. Additionally, shoulder dystocia occurs most often with large fetuses, long labors, quick labors, maternal obesity, and maternal diabetes.
Lastly, not all risks create both abnormal position and presentation. For instance, the fetus facing the mother’s front may occur even though the fetus is vertex down the canal. In other words, risk factors may create either an unusually positioned baby or an outside of the norm presentation before the baby is delivered. In both scenarios, it is essential for doctors to assess and properly determine which way the baby is set to leave the canal and whether their face is toward the mother’s spine or her abdomen.
How can they Tell which way your Baby is Positioned?
Since complications from abnormal presentation and position are life threatening, the first preventative practice is to assess each patient for risk factors, by checking the patient’s medical history for prior pregnancies, placenta previa, obesity, and diabetes. A physical exam, sonogram, or other prenatal tests may detect abnormalities in the shape of the uterus, position of the placenta, the amount of amniotic fluid, or a narrow pelvis, especially if a fetus appears large in later weeks of pregnancy. Ensuring that conditions like diabetes and obesity are treated is also important. In addition, through physical exam, sonogram, genetic testing, and other prenatal tests, birth assistants and medical personnel can assess whether the fetus has hydrocephalus or other conditions that affect fetal position or presentation. Further, rigorously checking for abnormal presentation or position starting in late term, around 36 weeks, at each doctor visit is crucial.
How do Doctors Handle Abnormal Birth Presentation?
If detected, a birthing mother may need a full spectrum care for emergency delivery by c-section, if necessary. Depending on the case, some deliveries are best handled by specialists who regularly perform complicated deliveries. In addition, physicians must be informed and experienced with various labor and delivery techniques and testing methods, including the mastery of birth assistance instruments, fetal monitoring, and advanced manipulation techniques to shift the fetal position.
When deciding the best course of action, it depends on the type of abnormality. For example, if the baby is breech, this requires repositioning if possible. On the other hand, if the fetus is face forward, it may reposition naturally or may not, in which case further action may be necessary. If possible, an experienced doctor may try to reposition the baby in utero or refer the patient to someone who can. They may also recommend the patient do specific exercises to try to turn the baby prior to the birth itself. Patients must be monitored carefully to ensure they are doing the exercises safely and that the unborn child is doing well. Assessing and timing of the next step is critical. In other positions, the physician and assisting personnel must be prepared for instrument delivery, cesarean section, and other appropriate medical interventions based on the baby’s position and presentation.
When dealing with a breech presentation, a mother has better chances of vaginal birth if the breech presentation is known before delivery, when a doctor can attempt to turn the fetus around in the womb. Also, if discovered early, a physician can take steps to prevent premature labor by the administration of medication. If unable to right the fetus’s presentation, the baby may have to be delivered by c-section to prevent brain damage or death. In the case of brow presentation, if the fetus does not re-adjust naturally, an obstetrician may resort to a c-section delivery. Similarly, if the fetus’s shoulder is first down the birth canal but the body is horizontal, a c-section generally results. If the fetus is transverse lying, the patient should be prepared for cesarean delivery and preparations made. Moreover, there are multiple ways to address shoulder dystocia, including specially-designed maneuvers and other methods. For instance, a doctor may cut the vaginal opening to widen it, known as an episiotomy, and try to maneuver the baby out. However, errors and inexperience with this risks damage to the arm or shoulder nerves or a broken arm or collarbone. Even after cutting and maneuvering, a c-section may still be necessary.
What can Happen in Delivery if the Baby is Abnormally Situated?
Once labor starts and the fetus is abnormally situated, complications may arise, such as premature membranes breaking, weak or extremely painful contractions, entering labor too soon, excessively long labor, uterine rupture, fetal distress, excessive bleeding after birth, and other dangerous complications, all of which risk the lives and overall health of the mother and the newborn. If such complications do occur, time is of the essence and can even save the infant or mother’s life. The reality is that after care for the mother and baby for bleeding, oxygen, and repairs to any injuries suffered during delivery must be immediate. Failure to act in a timely manner can cost someone their life; it equally amounts to medical malpractice. Still more, failing to detect the abnormal position or presentation before labor may be the clearest example of malpractice and the source of serious birth injuries or wrongful death for the mother or her child.
Ultimately, any missteps along the way can lead to devastating results, permanent neurological damage, cerebral palsy and conditions resulting from brain injury, hemorrhaging, or prove fatal. All medical professionals must perform their duties so as not to cause unnecessary injury or death to patients, nor to cause the unnecessary pain and suffering inevitably resulting from these events. Being unprepared, undereducated, overtired, or inexperienced is unacceptable, plain and simple. It may also be cause for liability.
If Someone Mishandled Your Fetal Abnormal Positioning, You Have Rights
If you would like to discuss a situation in which mismanagement of an abnormal birth position or presentation caused harm to you or someone you love, contact us now at 866-708-8617 for a free consultation. An attorney with extensive experience achieving compensation on behalf of those injured during birth throughout New Jersey, and consulting on these cases nationwide, is standing by to assist you.