7.3 Malposition, Manual Rotation, Breech, Face Presentation & Nuchal Cord

Recognizing Fetal Malposition and Malpresentation

The blueprint asks the midwife to perform manual rotation of the fetus in occiput posterior position, and to attend births of infants in occiput posterior, breech, and face presentations and manage nuchal cord. All four begin with an accurate assessment of position.

• Abdominal palpation (Leopold's): in occiput posterior the fetal back is not palpable as a smooth convexity on either side; instead small parts are felt anteriorly across the maternal abdomen, and fetal heart tones are best heard in the maternal flank rather than the lower quadrant.
• Vaginal examination: identify the fontanelles. The posterior fontanelle is small and triangular with three sutures meeting; the anterior fontanelle is large and diamond-shaped with four sutures. Palpating the diamond-shaped anterior fontanelle in the anterior pelvis means the occiput is posterior.
• Bedside ultrasound confirms position more reliably than digital examination and should be used when the exam is equivocal.

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Persistent Occiput Posterior

Roughly 15–30% of fetuses are occiput posterior at the onset of labor; most rotate spontaneously, and only about 5–8% persist to birth. Persistent OP produces intense lumbosacral "back labor," a prolonged active phase and second stage, an early urge to push before full dilation, and a markedly higher rate of operative birth and third- and fourth-degree laceration.

Positional and Supportive Measures

Hands and knees reliably relieves back pain and is recommended on that basis; Cochrane evidence that any maternal position actually rotates the fetus is weak, so position change is offered for comfort and pelvic mobility rather than promised as a rotation technique. Useful options include hands and knees, open knee-chest, asymmetric lunges, side-lying with the upper leg supported, and walking with stair-stepping.

Manual (Digital) Rotation

Manual rotation converts a persistent OP or occiput transverse to occiput anterior and, when successful, substantially reduces operative vaginal birth and cesarean. Reported success rates range widely, roughly 50–90%, depending on operator experience.

Prerequisites: full cervical dilation, ruptured membranes, an engaged head at station 0 or below, an empty maternal bladder, adequate analgesia, and the ability to proceed to an alternative plan immediately.

Technique:

1. Confirm position by palpating the sagittal suture and both fontanelles.
2. Digital technique: place two fingers along the lambdoid suture beside the posterior fontanelle. Whole-hand (Tarnier) technique: insert the hand with the palm against the occiput, fingers toward the maternal sacrum.
3. Between or at the start of a contraction, first flex the head, then rotate the occiput anteriorly — for a left occiput posterior rotate clockwise (toward the maternal right), and for a right occiput posterior rotate counterclockwise, always moving the occiput the short way to the pubis.
4. Hold the head in the new position through one to two contractions while the patient pushes, so the head engages in the new orientation. An assistant may guide the fetal shoulders abdominally in the same direction.
5. Reassess the fetal heart rate immediately after the attempt.

Risks: cord prolapse if the head is displaced upward, cervical laceration, fetal scalp trauma, and a transient fetal heart rate deceleration. Abandon the attempt if rotation is not achieved in one or two contractions. Manual rotation is within midwifery scope in many settings but requires institutional privileging and documented competence.

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Face and Brow Presentation

Face Presentation

Face presentation results from complete extension of the fetal head and occurs in roughly 1 in 500–600 births. Risk factors include anencephaly, fetal neck masses, prematurity, high parity with lax abdominal musculature, and cephalopelvic disproportion.

• Presenting diameter: the submentobregmatic, about 9.5 cm — the same as a well-flexed vertex, which is why vaginal birth is possible at all.
• Diagnosis: palpation of orbital ridges, nose, malar eminences, and the mouth (a gloved finger may be gripped by the fetal mouth). Distinguish the mouth from the anus of a breech: the mouth has a hard alveolar ridge and is a triangle with the malar bones; the anus is in a straight line with the ischial tuberosities. Confirm with ultrasound.
• Classification is by the chin (mentum):
  • Mentum anterior (MA): the chin rotates under the symphysis and the head delivers by flexion. Vaginal birth is achievable in most cases.
  • Mentum posterior (MP): the fetal neck would have to extend further than anatomically possible to negotiate the sacral curve. Vaginal birth is not possible and cesarean is required.
  • Mentum transverse: most rotate to mentum anterior.

[!CAUTION] In face presentation, never attempt to convert the face to a vertex manually, never apply a vacuum, and never attempt internal rotation of the head. Expect significant facial edema and bruising, and observe the newborn for airway edema and feeding difficulty.

Brow Presentation

Brow presentation is partial extension, presenting the occipitomental diameter of about 13.5 cm — the largest fetal cranial diameter. Most convert spontaneously to a face or a vertex during labor. A persistent brow presentation at term cannot deliver vaginally and requires cesarean birth.

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Breech Birth

Types

Planned Mode of Birth

After the 2000 Term Breech Trial, planned cesarean became standard in the United States. Later observational data (notably the French PREMODA study) show that planned vaginal breech birth can be safe with strict selection criteria and a skilled attendant, and ACOG permits planned vaginal breech birth under hospital-specific protocol. The practical reality for most CNMs is that breech birth is encountered unexpectedly or precipitously, so the maneuvers must be known.

External Cephalic Version (ECV)

Offered at 36 0/7 to 37 0/7 weeks or later, with an overall success rate near 60%. It is performed near an operating room with continuous fetal monitoring, often with tocolysis (terbutaline) and regional anesthesia to improve success. Administer RhD immune globulin to unsensitized Rh-negative patients afterward.

Maneuvers for Vaginal Breech Birth

1. Hands off the breech. Do not touch or apply traction until the umbilicus is visible. Traction extends the fetal arms and deflexes the head — the two mechanisms that cause disaster.
2. Allow maternal expulsive effort to deliver the body to the scapulae; keep the fetal back anterior.
3. Løvset maneuver for nuchal (extended) arms: grasp the fetal pelvis over the bony hips, rotate the trunk 180° to bring the posterior arm anteriorly under the symphysis, sweep it down, then rotate back for the other arm.
4. Mauriceau-Smellie-Veit maneuver for the after-coming head: rest the fetal body on the operator's forearm, place the index and middle fingers on the fetal maxilla (never the mandible) to flex the head, with the other hand's fingers on the shoulders and suprapubic pressure from an assistant to maintain flexion.
5. Piper forceps may be applied to the after-coming head by a trained operator.
6. Head entrapment — particularly in a preterm breech, where the body delivers through an incompletely dilated cervix — is managed with Dührssen incisions to the cervix at 2, 6, and 10 o'clock, or in extremis symphysiotomy or the Zavanelli maneuver with cesarean.

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Nuchal Cord

A nuchal cord is present in roughly 20–35% of births and is usually an incidental finding without adverse outcome. A nuchal cord is not an indication for cesarean birth, and tight or multiple loops may produce variable decelerations in labor.

Management after the head is born:

1. Slide two fingers along the fetal neck to feel for a cord.
2. Loose cord: slip the loop over the head, or simply allow the body to deliver through the loop.
3. Tight cord: use the somersault maneuver — hold the fetal head flexed close to the maternal perineum and allow the shoulders and body to deliver by somersaulting out, then unwrap the cord. This preserves the circulation completely.
4. Cutting the cord before the body is born is a last resort. It converts the newborn to a state with no placental oxygen supply while the body is still undelivered; if the shoulders then prove difficult, the fetus is rapidly asphyxiated. Reserve it for a cord that cannot be reduced by any other means, and be prepared to expedite the birth and resuscitate immediately.