C H A P T E R 6 4 
Unstable Lie, Malpresentations,
and Malpositions
IAN Z. MACKENZIE
INTRODUCTION
The concepts of unstable lie, malpresentation, and malposi-
tion have not changed for centuries probably, and there is
no reason to anticipate a significant change will present in
the foreseeable future. Various techniques for improving
diagnostic accuracy and clinical care are periodically pro-
posed and either become established clinical practice or
disappear, sometimes to be resurrected at a later date.
Near term and during labor, the fetus usually assumes a
longitudinal lie and presents to the maternal pelvis with the
head, the neck flexed, and the vertex in the lowermost part
of the uterus. In approximately 5% of labors, the lie is not
longitudinal; this can be dangerous for both mother and
fetus and demands intervention. As with much of medicine,
the prior identification of the pregnancy at particular risk for
unstable lie, malpresentation, or malposition can prompt
intervention in advance of a complication developing and
improve the outcome. Although relevant to unstable lie and
malpresentation, this chapter does not consider issues relat-
ing to fetal breech presentation in detail because these are
dealt with elsewhere (see Chapter 63).
DEFINITIONS
Unstable Lie
Unstable lie is a description generally used beyond 37 weeks’
gestation when the fetal lie and presentation repeatedly
change, the lie varying between longitudinal, transverse, and
oblique, and the presentation between cephalic, limbs,
breech, or a combination. Conventional wisdom teaches
that the fetal presentation will not be cephalic at the start
of the third trimester in around 25% pregnancies and this
proportion drops to around 3% to 5% by term. This teach-
ing is supported by longitudinal ultrasound examination
studies.1–3
By 37 weeks’ gestation, the fetus usually adopts a “stable”
lie and presentation that will be unchanging until labor; fetal
position, describing the relationship of the fetal back to the
maternal side, may and often does change. A longitudinal
fetal lie is, however, unlikely to change once labor has estab-
lished, unless the presenting part is “high” in relation to the
pelvis, and particularly if there is polyhydramnios or the
maternal abdominal wall muscles are weakened by high
parity.
Malpresentation Including
Compound Presentation
The presenting part is defined as that part of the fetus that is
lowermost in the uterus. The vertex is the “normal” and most
common presenting part. The alternatives include face,
brow, breech, and shoulder; compound presentations involve
more than one fetal part presenting to the pelvis. This may
include a combination of the head with a limb or limbs and
any presentation that includes the umbilical cord.
Malposition
Fetal malposition occurs when the vertex presents to the mater-
nal pelvis in a position other than flexed occipitoanterior.
Malpositions thus include occipitotransverse and occipito-
posterior positions and may involve asynclitism (sideways
tilt of the head).
Figure 64–1 shows the various positions that the vertex,
brow, or face may adopt during labor.
ETIOLOGY
Unstable Lie
Unstable lie is much more common in parous than in nul-
liparous women and may be caused by or associated with a
number of factors. Any situation that discourages or prevents
the fetal head or breech from entering the maternal pelvis
may predispose to an abnormal and/or unstable fetal lie.
Figure 64–2 illustrates many of these factors.
Maternal Factors
HIGH PARITY
Reduced maternal abdominal wall muscle tone leading to a
failure to brace and maintain a longitudinal fetal lie is prob-
ably the most frequent factor. There is a commonly held
view that the highly parous uterus also has reduced muscle
1123
1124    S ECTION S IX • Prenatal—General

VERTEX PRESENTATIONS FACE AND BROW PRESENTATIONS

RMA LMA
ROA LOA

ROT LOT RMT LMT

FIGURE 64–1 
Diagramatic representation of the positions  
ROP LOP RMP LMP for vertex, brow, and face presentations.  
A, anterior; L, left; M, mento; O, occipito;  
R, right; T, transverse.

Multiple
High parity pregnancy

Fundal
Uterine placenta
anomaly
Hydramnios

Pelvic cyst
or fibroid Fetal anomaly

Distended Macrosomia
bladder

Pelvic Placenta FIGURE 64–2 

contracture previa Etiologic factors and conditions associated with unstable
fetal lie.

tone, thereby contributing to instability of the fetal lie, but
this has not been proved and is, therefore, of questionable
relevance.
PLACENTA PREVIA
A persistently changing fetal lie may be the only clinical
feature leading to the diagnosis of placenta previa. In addi-
tion, the placenta situated in the fundus may also predispose
to an unstable lie.4
PELVIC CONTRACTURE
Reduced pelvic dimensions or a distorted pelvic cavity due
to congenital malformation, disease processes compromising
bone development, or trauma to the pelvis, can prevent the
presenting pole engaging in the pelvis in late pregnancy.
PELVIC TUMORS
Ovarian cysts of only moderate dimensions situated in the
pouch of Douglas and fibroids in the lower pole of the
uterus, as well as those that are pedunculated and occupy-
ing the sacral curve, can prevent the fetal head or breech
entering the pelvis and predispose to a transverse or
oblique lie.
UTERINE MALFORMATION
Uterus cordiformis, subseptus, or septus can be causative,
but more severe forms of anomaly including uterus unicor-
nis, bicornis, and didelphys are less likely to lead to an
unstable lie because of the restricted capacity of the uterine
cavity; a predisposition to fetal breech presentation,
however, often results.
DISTENDED MATERNAL URINARY BLADDER
Maternal urinary retention with bladder distention can cause
a changing fetal lie, usually only temporarily, with resolution
occurring with urinary voiding or bladder catheterization.
 C HAPTER 64 • Unstable Lie, Malpresentations, and Malpositions     1125
Fetal Factors
POLYHYDRAMNIOS
Polyhydramnios (excessive volumes of amniotic fluid) may
produce marked uterine distention, enabling the fetus to
move around more freely. This probably represents the most
common “pathologic” cause for an unstable lie and is also
potentially the most hazardous for mother and fetus (see
Chapter 12).
OLIGOHYDRAMNIOS
By restricting fetal movement, oligohydramnios can prevent
the fetus presenting by the breech from undergoing com-
plete spontaneous version to cephalic.
MULTIPLE PREGNANCY
The discovery of an abnormal lie during the last 3 weeks of
pregnancy may arouse suspicion of a multiple pregnancy and
lead to investigations that result in the diagnosis being
reached. Nowadays, such a diagnosis is unlikely to have
been missed until this stage of pregnancy with the wide-
spread use of routine ultrasonography during the first 20
weeks of gestation. When the lie of one or both fetuses
repeatedly changes, there is usually polyhydramnios.
FETAL MACROSOMIA
Fetal macrosomia produces the same effect as pelvic contrac-
ture and must also be considered in such cases.
FETAL ABNORMALITIES
Significant hydrocephaly, tumors of the fetal neck or sacrum,
fetal abdominal distention as with hydrops fetalis, and fetal
neuromuscular dysfunction (including extended legs) may
impede or discourage engagement of a fetal pole in the
maternal pelvis. In cases of intrauterine death, the fetus is
more likely to present abnormally due to loss of tone, some-
times requiring delivery by cesarean section because vaginal
birth is impossible.
Compound Presentation
Compound presentations are most usually associated with
polyhydramnios and high parity and are more common
during the early weeks of the third trimester. Multiple preg-
nancies, especially monoamniotic, represent a particular risk.
Pelvic tumors, including uterine fibroids situated low in the
uterine body or an ovarian cyst situated in the pouch of
Douglas, also predispose to compound presentations.
Malpresentations that involve the umbilical cord are simi-
larly associated with the factors previously mentioned. Fetal
breech presentation, especially with one or both knees
flexed, is the most common malpresentation associated with
cord presentation and prolapse.5–8 Abnormalities of the cord,
including reduced content of Wharton’s jelly, true knots,
and chronic fetal acidosis reducing tissue turgidity, have
been cited as predisposing factors.9
Brow and Face Presentations
The majority of cases of brow and face presentation are
thought to arise when there is a minor degree of deflexion
of the presenting vertex, which then undergoes further
extension. With increasing extension, a brow becomes a face
presentation. This may occur during the antepartum period,
resulting in a primary face presentation, or during labor,
resulting in a secondary face presentation. Primary presenta-
tions are generally associated with fetal malformations,
including anencephaly, meningocele, dolichocephaly, con-
genital branchiocele, goiter or other anterior neck tumors,
and tense extensor neck muscles. Polyhydramnios with the
increased space within the uterus and a tight nuchal cord
have also been implicated as predisposing factors. Secondary
presentations are thought to be associated with a contracted
or abnormally shaped pelvis. This was considered respon-
sible for 40% of face presentations in a series reported from
the Johns Hopkins Hospital early in the last century.10 It is
also much more common in preterm labor, probably due to
the more capacious pelvis being able to accommodate the
relatively small fetus.11
Malpositions
Data derived from ultrasound examinations at the start of
labor have suggested that the majority (68%) of occipito-
posterior positions confirmed toward the end of labor were
in an occipitoanterior position at the beginning of labor; the
other 32% were initially in an occipitoposterior position,
and these labors are more likely to result in an assisted
delivery.12
Pelvic shape is probably the major determinant of fetal
position prior to labor. When the anteroposterior dimension
of the pelvic brim equals or exceeds that of the transverse
dimension (the android pelvis), occipitoposterior positions
are favored. Thus, women with an android pelvis are more
likely to have an occipitoposterior position in late preg-
nancy and at the start of labor because the larger dimensions
toward the back of the pelvis encourage the broader occiput
to be accommodated there rather than in the anterior com-
partment. In addition, when there is a high-assimilation
pelvis with an extra vertebra included in the formation of
the sacrum, the inclination of the brim increases and favors
an occipitoposterior position. The much less common
anthropoid-shaped pelvis, with lessening of the posterosag-
ittal diameter (the distance between the midpoint of the
widest transverse diameter and the sacrum), affects not only
the brim but also commonly extends to the lower levels of
the pelvis and to the outlet. In particular, the concavity of
the sacrum from promontory to tip is often reduced or abol-
ished (flat sacrum), leaving a reduced space in which the
sinciput can turn, should internal rotation commence. This
leads to the head becoming impacted in the pelvis, resulting
in a “deep transverse arrest.” It has been suggested that
increased muscle tone in the extensor muscles of the fetus
might also predispose to an occipitoposterior position, but
there is little evidence to support this theory.
Most important is the observation that a high proportion
of women with a malposition who make poor progress
through labor often respond to augmentation of uterine
contractions with oxytocin and achieve a successful sponta-
neous vaginal delivery.13 This suggests that the quality of
uterine contractions plays a significant part in determining
the position and attitude of the fetal head. As well as uterine
contraction strength being important, there is now good
evidence that the tone of the pelvic floor is relevant. Use of
1126    S ECTION S IX • Prenatal—General
regional anesthesia for the management of pain relief during
labor has been implicated as a mechanism for the increased
rates of malposition in late labor,14,15 although this is dis-
puted. Regional anesthesia provides an extremely effective
method of reducing the distress of labor, distress that is more
common with a preexisting occipitoposterior position. The
issue of cause and effect thus comes into play. The experi-
ence reported from Dublin provides some evidence to
suggest that regional blockade is not causal in the evolution
of fetal malposition. It was noted that despite a 30-fold
increase in intrapartum epidural usage between 1975 and
1998, occipitoposterior position at the end of a first labor
decreased from 3.8% to 2.4%.15,16
INCIDENCE
Unstable Lie
Figures are not generally available for the incidence with
which unstable lie is encountered antenatally; it is influenced
by the proportion of multiparas and particularly the numbers
of grand-multiparas in the population. Also, in societies
where malnutrition is prominent and maternal or fetal skel-
etal deformities are relatively more common, the incidence
will be higher. In a well-nourished and developed population
where high parity (>4) is uncommon, the incidence will be
in the range of 0.1% to 1.0%, and the occurrence rate of
transverse lie in labor is in the region of 0.4%.17
Compound Presentations
There is a relatively sparse literature on the incidence of
compound presentations that involve one or more limbs and
the fetal head or breech. Overall, the incidence has been
quoted to be between 1 in 377 and 1 in 1213 deliveries18–20;
personal experience suggests that the lower incidence is
more usual in the developed world. Combinations involving
the upper limbs and head are the most common. Diagnosis
in late labor is the usual situation, with as many as 50% of
compound presentations being diagnosed during the second
stage of labor.
The incidence of cord presentation, when a segment of
umbilical cord is situated between the fetal presenting part
and the cervix with intact membranes, has not been widely
reported. although cord prolapse, by definition following
membrane rupture, occurs in around 1 in 300 to 1 in 700
total births,5,7,21,22 1 in 900 cephalic presentation labors, 1 in
56 breech labors, 1 in 23 twin labors,7 and 1 in 5 to 1 in 10
compound presentations that involve a limb.18,19,23 Thus,
cord prolapse in a singleton pregnancy with a cephalic pre-
sentation at term has an incidence of around 1 in 1400
labors. These rates are almost certainly lower than the inci-
dence of cord presentation, because recognized cord presen-
tation is likely to be managed by cesarean section before
prolapse occurs.
Brow and Face Presentation
Face presentation in labor has an incidence of between 1 in
200 and 1 in 500 labors24–26 and brow presentations around
1 in 600 to 1 in 1500 deliveries.27–29 The incidences during
pregnancy are less well documented, especially for brow
presentation, because it is probable that this presentation is
only transient, with reversion to vertex presentation with
flexion of the neck or face presentation with further
deflexion.
Malpositions
During the antepartum period, prior to the onset of labor,
the occipitoposterior position exists in around 11% of sin-
gleton pregnancies.30,31 Once labor starts, the incidence is in
the region of 20% to 25%; if the fetal back is on the maternal
left, the occipitoposterior position is much less common
than when the back is on the maternal right.20 It is said to
be more common in cases of membrane rupture before the
onset of labor, with an incidence of 27%.32 When there is
an occipitoposterior position at the start of labor, this posi-
tion will remain to the end of labor in 20% to 35%, indicat-
ing that 65% to 80% undergo spontaneous rotation during
labor. Only approximately 1% to 5% are delivered in an
occipitoposterior position.33,34
DIAGNOSIS
Unstable Lie
This diagnosis is made when a varying fetal lie during the
last month of gestation is found at repeated clinical examina-
tions. Occasionally in those women in whom clinical exami-
nation is not easy (including those with a raised body mass
index), the diagnosis may fortuitously be made by an ultra-
sound examination performed for other reasons. An unstable
lie would appear to be more common than is presently
thought, from the evidence of the frequency with which
fetal breech presentation is missed prior to the onset of labor
despite frequent and recent antenatal clinical examinations.
Further, the observation of spontaneous and unexpected
version of the fetus from a cephalic to breech presentation
during the last weeks before birth adds weight to this
observation.35,36
Compound Presentations
A compound presentation involving a fetal arm with the
head or an arm with a leg is likely to be diagnosed only
during the antepartum period as a coincidental finding at an
ultrasound examination or rarely on radiographic or mag-
netic resonance imaging. The high nonengaged head that
cannot be encouraged into the maternal pelvis might prompt
an ultrasound examination that leads to the diagnosis.
Diagnosis during labor may be suspected because of delay
in the presenting part entering the pelvis, which is confirmed
on vaginal examination by identifying the errant limb or
limbs. Occasionally, the diagnosis is made unexpectedly at
a vaginal examination during preterm labor when the mater-
nal pelvis is large and the interloping limb with the head or
breech does not delay engagement of the presenting part.
Compound presentations involving the umbilical cord are
usually classified according to Naegele, who distinguished
“presentation” before membrane rupture and “prolapse” after
membrane rupture. A diagnosis of cord presentation will
not usually be made prior to the onset of labor except
in those cases of an unstable lie when a vaginal examination
 C HAPTER 64 • Unstable Lie, Malpresentations, and Malpositions     1127
RIGHT MENTO-POSTERIOR
POSITION
FIGURE 64–3 
Palpation of the fetus and the landmarks
associated with a face presentation.
is performed as part of the assessment for the strategy
for continued management. Although some have docu-
mented reaching the diagnosis with ultrasound, this is not a
widely reported observation,37 and cord prolapse occurring
during subsequent labor appears to be an infrequent
consequence.38
Face Presentation
Older texts report that abdominal palpation allows the diag-
nosis of face presentation by the recognition of a much
broader than usual lower pole presenting to the pelvis and
the marked depression between the fetal back and the
occiput (Fig. 64–3). This is more easily demonstrated if the
fetus is lying in a dorsoanterior or mentoposterior presenta-
tion, which is less common than a mentoanterior presenta-
tion.24 It is also said that the fetal heart sounds are very easily
heard when listened to over the fetal chest, especially with
a mentoanterior position; this potentially valuable clinical
sign is lost if hand-held Doppler machines are routinely used
to detect fetal heart pulsations in preference to a Pinard
stethoscope. Despite this, the author’s experience is that
these clinical signs are difficult to elicit, even in those cases
of face presentation already confirmed by radiology or
ultrasonography.
Confirmation of the presentation should be made by
vaginal examination during the intrapartum period. The
obstetrician, however, should be wary of confusing a face
and a breech presentation; facial edema readily forms during
labor and, with the added difficulty associated with a high
presenting part and a poorly dilated cervix, differentiation
can be difficult. Identification of the supraorbital ridges, the
ridge of the nose, and the alveolar processes within the
mouth should establish the diagnosis. If the technology is
available, an ultrasound examination can be used to confirm
the clinical suspicion.39
Brow Presentation
Although occasionally a brow presentation may be recog-
nized during the antenatal period, usually coincidentally at
LEFT MENTO-ANTERIOR
POSITION
an ultrasound examination, this is not permanent in most
instances. The suspicion of a broader than expected head
resting above the pelvic brim compared with the size of the
body may (rarely) lead the astute clinician to suspect this
possibility. Diagnosis during the intrapartum period is likely
to be made only in advanced labor when the cervix is mod-
erately well dilated and the brow is palpable to the examin-
ing fingers. Identification of the anterior fontanelle and the
supraorbital ridges confirms the diagnosis, but any signifi-
cant caput succedaneum can mask these landmarks. As with
face presentations, ultrasound examination is the most prac-
tical way to confirm or refute the diagnosis.
Malpositions
It is often written that the outline of the distended uterus
occasionally suggests an occipitoposterior position by the
“flatness” and a dip between the head and the trunk. Cer-
tainly, fetal movements may be readily observed over much
of the anterior surface of the abdomen if the baby is active
at the time of the examination. However, the fetal back may
be difficult to identify on palpation, although the shoulder
is felt toward the flank with the limbs often obvious to palpa-
tion over the abdomen. With Pawlik’s grip, the sinciput is
said to be prominent, but personal experience would not
suggest this to be a reliable feature. Importantly, the fetal
heart is heard maximally in the flank to which the back is
directed; the Pinard stethoscope allows this clinical sign to
be elicited whereas the small Doppler fetal heart detectors
generally do not. An ultrasound examination would confirm
or refute the clinical findings.
During labor, the anterior fontanelle is easier to reach
when the position is occipitoposterior rather than occipito-
anterior, although caput succedaneum can make this diffi-
cult, especially late in labor. Palpation of the more anterior
ear can be helpful, but this may be misleading if the pinna
has been turned forward. At this examination, not only the
degree of flexion but also any asynclitism should be noted.
Diagnosis of a deep transverse arrest should not present dif-
ficulties unless there is marked caput succedaneum or promi-
nent asynclitism. Once again, palpation of the fetal ear could
1128    S ECTION S IX • Prenatal—General

be helpful, or if available, ultrasound to confirm the FIGURE 64–4 

position.40,41 Fetal shoulder presentation, illustrating the site of a Bandl
or retraction ring, forming at the junction of the upper and
lower uterine segments in an obstructed labor.

RISKS
Unstable Lie and Compound Presentation
There are no hazards to mother or fetus during the antenatal
period from unstable lie per se. It is possible that cord entan-
glement is a greater risk, although this has not been posi-
tively shown. During the latter weeks of pregnancy,
spontaneous resolution to a longitudinal lie before the onset
of labor occurs in approximately 85%.42–44
There are, however, very serious risks to mother and fetus
with the onset of labor if the lie is not longitudinal. Once
the membranes rupture, with or without accompanying
uterine contractions, there is approximately a 9% risk of
cord prolapse if the fetal lie is oblique or transverse or the
presenting part is high above the pelvic inlet.45 This may
result in damaging hypoxia or even stillbirth; perinatal death
has generally been reported in 5% to 10% of cases7,46,47 or,
according to one series, as high as 43%.48 The risk of hypoxic
damage is less well documented and it may be as infrequent
as 1% in survivors,7 although this must depend on the speed
and availability of first aid to rescue the situation. Keeping
the interval between cord prolapse and delivery as brief as
possible is likely to be important.46,49
If labor starts when the lie is not longitudinal, a compound
presentation may result or the pelvis may remain empty. If
left unattended, fetal distress will eventually supervene, ulti-
mately resulting in fetal death. A Bandl or retraction ring
(Fig. 64–4) may form, making delivery even by cesarean
section potentially hazardous.50 In addition, uterine rupture
is a real possibility especially in multiparas, with an inci-
dence of 3%,45 with potentially serious consequences for Except with very preterm labor, the fetus cannot be deliv-
mother and fetus (see Chapter 67). ered as a persistent brow unless there is a very capacious
pelvis, because of the large mentovertical diameter that pres-
Malpresentation ents to the pelvis (see Fig. 64–5). If continued extension of
the neck to a face presentation does not occur and the brow
Face presentation persists, the chances of fetal distress and even
Cord prolapse may be marginally increased with a face over uterine rupture in a parous woman are high if labor is not
vertex presentation, but once established in labor with the progressing and left to continue for too long.
head engaged in the pelvis, this is no more likely. Progress
should be as for a vertex presentation without any additional
risk to the fetus because the presenting head diameters are Malpositions
similar (Fig. 64–5). However, with the largest presenting Few risks are associated with a fetal malposition prior to
diameter (biparietal) displaced toward the back of the pelvis, labor. As already stated, there is a belief that prelabor rupture
a generous episiotomy should be performed to reduce the of the membranes is more common with an occipitoposte-
risk of a third-degree tear. Providing the face is mentoante- rior position. Because the head is usually not engaged and
rior, vaginal delivery is likely. If there is any delay in deliv- may not be well settled into the pelvis, the risk of cord
ery, assistance with forceps is appropriate but the ventouse prolapse is marginally increased.
is contraindicated because it cannot be applied safely with Once in labor, progress may be slower than with an occip-
a face presentation. The parents should be advised in advance itoanterior position and maternal discomfort is often
of delivery that their baby will initially appear very unat- increased, particularly in the back. In addition to a pro-
tractive owing to the inevitable bruising and marked edema, tracted first stage of labor, there is often a delay during the
both of which disappear within a few hours of birth. second stage with the need for augmentation of contractions
with oxytocin, and maybe manual rotation or instrumental
Brow delivery using ventouse or forceps with or without initial
There are no added risks to the mother with a fetal brow rotation. With the present reluctance to engage in rotational
presentation during the antenatal period. As with a face forceps deliveries, especially if fetal distress is suspected,
presentation, the risk of cord presentation and prolapse is together with the higher failure rates with the ventouse,
increased. delivery by cesarean section is increased.
 C HAPTER 64 • Unstable Lie, Malpresentations, and Malpositions     1129

Submentobregmatic
(in face presentation)

Mentovertical
(in brow presentation)

13.5 cm

9.5 cm

11.0 cm
Occipitofrontal
(in occipito
posterior position)
9.5 cm

Suboccipitobregmatic
(in vertex presentation)
FIGURE 64–5 
The largest sagittal dimensions of the fetal head according to
presentation.

Unstable lie

Expectant Admission at 37–39

management weeks’ gestation

Expectant Intervention

Spontaneous Persistent External Stabilizing

version to unstable lie version to labor
long lie long lie induction

Success Failure Failure Success

FIGURE 64–6 
Algorithm for the antepartum management of unstable lie in
Labor Labor Cesarean section Labor
late pregnancy.

It has been shown by one group that the occipitoposterior
position that persists to the time of vaginal delivery presents
a significant risk of anal sphincter damage for all parities.16
MANAGEMENT OPTIONS
Unstable Lie and Compound Presentation
Prenatal
During the antenatal period, management can be expectant
or active, whereas delivery can either await spontaneous
onset of labor or be arranged as a planned event. An algo-
rithm of the various options is illustrated in Figure 64–6.
EXPECTANT MANAGEMENT
Once an unstable lie is identified, no specific action is taken
in anticipation that the lie will become longitudinal before
the membranes rupture or labor starts: this is likely to occur
in more than 80% of cases.42–44 Manipulation to a longitudi-
nal lie at an antenatal examination can sometimes be per-
formed. Every attempt should be made to identify any
obvious mechanical cause for the unstable lie, especially if
it is likely to result in obstructed labor requiring elective
cesarean section. The patient should be advised of the risks
associated with an unstable lie and the need for urgent atten-
tion should labor start or the membranes rupture. If she lives
a long distance from the delivery unit, it may be wise to
1130    S ECTION S IX • Prenatal—General
admit her at 37 to 39 weeks’ gestation to await the onset of
labor to ensure prompt attention if required. A number of
physical exercises, including adopting the knee-elbow posi-
tion for short periods each day, have been advocated to
encourage spontaneous version, generally from a breech to
a cephalic presentation.51–54 Such maneuvers possibly
improve the chances of longitudinal lie by 5% to 10%, but
there is no established evidence base for this proposition.
ACTIVE MANAGEMENT
Admission is often advised from 37 to 39 weeks’ gestation,
which provides the opportunity for (1) daily observations of
fetal lie and presentation to be made, (2) active treatment to
correct the lie if necessary, (3) calling for immediate assis-
tance upon membrane rupture or the onset of labor, and (4)
urgent delivery if the lie is not longitudinal, fetal distress
occurs, or the cord is presenting or has prolapsed. Evidence
to support this approach is provided by one small study of
expectant management for unstable lie after 37 weeks’ gesta-
tion that reported that 17% presented in labor with a trans-
verse lie and 6% had a prolapsed cord resulting in neonatal
death in 1%.44 If spontaneous resolution to a longitudinal lie
occurs and a cephalic or breech presentation is maintained
for 48 hours, the women may be discharged home to await
labor. Some currently discourage labor with a breech pre-
sentation and reference should be made to the relevant
chapter on this topic (see Chapter 63). If spontaneous reso-
lution of an abnormal lie does not occur, an active approach
to management may be adopted. External cephalic version
can be attempted if facilities permit immediate delivery in
the event of placental abruption, membrane rupture, cord
prolapse, or acute fetal distress for any reason.49,55 Rhesus
immunoprophylaxis should be given to at-risk women either
before or soon after the version attempt, and an estimate of
the volume of any fetomaternal hemorrhage made about 20
minutes after the attempt at version, using the Kleihauer-
Betke method or flow cytometry to determine whether addi-
tional prophylaxis is necessary.56,57 If a longitudinal lie is not
maintained, the version can be repeated as often as neces-
sary, and if unsuccessful, the women should be kept in the
hospital after the birth. The success of version for unstable
lie is unclear, but it is probably greater than for breech pre-
sentation, which is usually quoted around 40% to 65%.46,48,58
Tocolysis can be used, including infusions of ritodrine
50 µg/min for 15 minutes46 or terbutaline sulfate 250 µg
intravenously over 1 to 2 minutes,31 but is often unnecessary
with a transverse or oblique lie (see Chapter 63).
In the event the lie remains unstable, a stabilizing induc-
tion may be performed usually at 38 to 39 weeks’ gestation.
Following transfer to the labor suite, an external cephalic
version is performed if necessary to convert the fetal lie to
longitudinal. Once the fetus is in position, regular abdominal
palpations are performed to confirm the lie is maintained and
a titrated intravenous infusion of oxytocin commenced to
stimulate uterine contractility.47 Although contractions can
also be stimulated with local (vaginal) or oral prostaglandins,
this is probably less advisable because the response to pros-
taglandins can be unpredictable and occasionally hyper-
stimulation occurs, which would be especially concerning if
the lie reverts to oblique or transverse, when tocolysis and/
or emergency cesarean section is required. As soon as con-
tractions are occurring at 10-minute intervals or more
frequently, a low amniotomy is performed, having ensured
at vaginal examination that the lie is still longitudinal, the
presentation is not compound, and in particular, the cord is
not presenting. If the cord presents, an emergency cesarean
section is necessary. Once low amniotomy is performed, a
reasonable volume of amniotic fluid should be released, fol-
lowed by confirmation that the cord has not prolapsed and
the presenting part is fixed in the pelvic brim. Thereafter,
once labor is established, management continues as for
uncomplicated cases, being ever mindful that cord prolapse
might still occur.
Hindwater amniotomy using a Drew-Smythe catheter59
can be performed providing a low posterior placenta has
been excluded by an ultrasound examination. The catheter
is guided through the cervix between the uterine wall and
the fetal membranes behind the presenting part, taking all
possible care to avoid trauma to the fetus and the uterine
wall. When in position, with the catheter tip above the
presenting part, the stylet in the catheter is advanced to
puncture the membranes and allow a controlled release of
amniotic fluid. This procedure aims to reduce the chances
of cord prolapse occurring, but it is rarely used in modern
practice.
Finally, a decision to deliver by elective antepartum cesar-
ean section at 38 to 40 weeks’ gestation is a legitimate
management option.44 Ideally, an attempt should be made
to convert the lie to longitudinal immediately before the
laparotomy or after opening the peritoneum but before
incising the uterus. If successful, a lower segment incision in
the uterus can be used for the delivery, but if the lie remains
transverse, the classic (vertical midline) incision may be pref-
erable to reduce the chances of fetal and uterine trauma
being caused by a difficult fetal extraction from the uterus.
Planned cesarean section is particularly appropriate if ante-
natal external cephalic version is contraindicated, previous
attempts at version fail, or there is a mechanical obstruction
to vaginal delivery.
Intrapartum
When the fetal lie is transverse or oblique and the mem-
branes rupture or labor starts, the options for management
are illustrated in the algorithm in Figure 64–7, which depend
on (1) whether there is a cord presentation or prolapse, (2)
the stage of labor whether before full cervical dilation or
during the second stage, and (3) whether the membranes are
intact or ruptured.
FIRST STAGE OF LABOR
Management depends on whether the fetal membranes are
intact or ruptured. With intact membranes, an external
version can be attempted. This is performed between con-
tractions with or without tocolysis to relax the uterus
before the attempt. Tocolytic agents that can be used in
this situation include β-agonists such as terbutaline infused
at 5 to 20 µg/min, salbutamol (albuterol) 2.5 to 4.5 µg/
min, ritodrine 100 to 350 µg/min,60 or the oxytocin antag-
onist atosiban, given as a single intravenous bolus dose of
6.75 mg.50 If the version is successful, a repeat vaginal
examination should be performed to exclude cord presen-
tation or prolapse. Once this has been confirmed, labor
can be allowed to establish, ensuring the lie remains longi-
tudinal until the presenting part engages in the pelvis,
 C HAPTER 64 • Unstable Lie, Malpresentations, and Malpositions     1131
Cord
presenting
Before full Full dilatation
dilatation
Version to
long lie if
necessary
Failure Success
Cesarean Assisted Continue
FIGURE 64–7  section vaginal labor
Algorithm for the intrapartum delivery
management of unstable lie.
with progress augmented with oxytocin if necessary. If the
version has been unsuccessful, delivery by cesarean section
should be performed (see later discussion). With ruptured
membranes, delivery by cesarean section is generally the
only option unless the woman is in very early labor and an
attempt at external cephalic version is successful. If there is
a compound presentation involving a hand or arm,
attempts should be made at vaginal examination to push
the arm up or nip one of the fetal fingers to try to encour-
age its withdrawal from in front of the head. It is also rea-
sonable to allow labor to continue with close supervision
in anticipation that spontaneous withdrawal will occur
with continuing uterine contractions causing discomfort to
the arm and hand; cord prolapse is a remote but real
possibility.
A shoulder presentation, which may include an arm pro-
lapsed into the vagina, is a serious situation (see Fig. 64–4).
Clamping of the uterine wall around the fetus by a retraction
or Bandl’s ring may have contributed. Delivery must be by
cesarean section. Administration of a uterine relaxant such
as halothane administered by the anesthetist can facilitate
the delivery, which is most safely achieved through a classic
uterine incision. This incision allows the fetus to be with-
drawn through the fundus of the uterus, whereas a lower
segment incision makes it nearly impossible to manipulate
the fetus into a position that will allow delivery without
damage to the fetus and uterus. This approach to delivery is
still indicated even if the fetus has already died, to avoid
uterine rupture and other serious uterine trauma at the time
of the delivery.
Vaginal
examination
No cord
presenting
Before full Full dilatation
dilatation
Intact Ruptured Ruptured Intact
membranes membranes membranes membranes
External Version to
version to long lie
long lie
Success Failure Failure Success
Cesarean Assisted
section vaginal
delivery
SECOND STAGE OF LABOR WITH INTACT MEMBRANES
If fetopelvic disproportion has been excluded, correction to
a longitudinal lie by external cephalic or internal podalic
version followed by an assisted vaginal cephalic or breech
delivery should be anticipated. If internal podalic version is
attempted, this requires adequate anesthesia (either general
or fully effective regional block). Using appropriate aseptic
techniques, the obstetrician introduces a hand into the
uterus, confirms the foot of the anteriorly positioned leg by
identifying the heel, and applies traction on the foot, with-
drawing the foot and leg and subsequently the breech
through the vagina (Fig. 64–8). It is ideal if both feet can be
grasped and pulled down, as this avoids the “splits,” with one
leg down and one leg up, which can splint the baby and lead
to a difficult delivery. The management is then as described
for breech extraction (see Chapter 63). Great care must be
taken to avoid both fetal bony injury and laceration of the
uterus. Tocolysis may be helpful for this procedure. If version
is not successful, delivery should be achieved by cesarean
section; attempts at version should be performed only when
immediate resort to section is available. The obstetrician
should be aware of the possibility of atonic primary postpar-
tum hemorrhage when uterine relaxants have been adminis-
tered to assist the delivery (see Chapter 75).
SECOND STAGE OF LABOR WITH RUPTURED MEMBRANES
If there is a compound presentation involving a hand and
the fetal head is engaged in the pelvis, it may be possible
with vaginal manipulation to encourage the hand to with-
draw from the pelvis so that an assisted vaginal delivery can
1132    S ECTION S IX • Prenatal—General
FIGURE 64–8  which may predispose to uterine rupture in future pregnan-
Principle of securing the foot of the anterior leg at internal podalic
version.
continue. Otherwise, cesarean section is required. If the
fetus is in a transverse or oblique lie or there is a significant
compound presentation, delivery should be performed as
urgently as possible using a classic cesarean section incision
unless an attempt at external version can be successfully
made on opening the abdominal wall immediately before the
uterus is incised. A transverse incision in the lower uterine
segment may be inadequate for fetal extraction because the
loss of amniotic fluid reduces the surgeon’s ability to manipu-
late the fetus within the uterus. Struggling to deliver the
fetus through a lower segment incision can cause serious
trauma to the fetus, uterus, or both, and the uterine incision
will probably need to be extended to an inverted T- or
U-shaped incision. Such incision extensions may result in
compromised healing and a vulnerable area of scar integrity,
SUMMARY OF MANAGEMENT OPTIONS
Unstable, Transverse, and Oblique Lie
Management Options
Prenatal (See Fig. 64–6)
Confirm diagnosis with ultrasound if necessary.
Investigate for possible causes including history and ultrasound examination.
Discuss options and risks.
Expectant Management
If noncephalic after 36 wk—“wait and see” policy—danger of cord prolapse
or admission in advanced labor with a malpresentation.
Advice to adopt knee-chest maneuver to promote cephalic version has not
been shown to be of value and is not recommended.
cies or labors.
CORD PRESENTATION AND PROLAPSE—FIRST STAGE
OF LABOR
With cord presentation, delivery by cesarean section should
be organized with some urgency if fetal distress is suspected.
Cord prolapse before full dilation of the cervix requires a
“crash” or “category 1” cesarean section. While preparations
are in hand for the surgery, an attempt should be made to
reduce any pressure on the umbilical cord that could restrict
or obstruct the cord circulation with consequent fetal
hypoxia. A number of strategies have been used or proposed.
Probably the most widely adopted involve applying digital
counterpressure with the gloved fingers within the vagina or
moving the patient into the Trendelenberg or knee-chest
positions.7,9 Alternatives recommended include bladder
catheterization and distention,11,61,62 administering tocoly-
sis,63,64 wrapping the exteriorized cord in warm saline-soaked
swabs, or manually replacing the cord into the vagina.21
Although the attempt at replacement of the cord may be
successful21 (see Chapter 69), there are concerns that its
manipulation might provoke vascular spasm of the vessels
and further compromise fetal oxygenation.65
CORD PRESENTATION AND PROLAPSE—SECOND STAGE
OF LABOR (See Also Chapter 69)
Cord presentation at full dilation may be managed by exter-
nal cephalic or internal podalic version if the lie is not
longitudinal, and following amniotomy, proceeding to
assisted vaginal delivery. Delivery by cesarean section
should be arranged urgently if the expertise for version is
not immediately available or the attempt is unsuccessful. If
cord prolapse has occurred and the lie is not longitudinal, a
crash/category 1 cesarean section is required. If the lie is
longitudinal, immediate vaginal delivery using forceps for a
cephalic presentation or breech extraction should be
advanced if the necessary skills are available and the present-
ing part is low enough in the pelvis.9 Because the ventouse
is associated with a higher failure rate than forceps, forceps
should perhaps be preferred if the necessary skill is
available.66–68
Evidence Quality and
Recommendation References
—/GPP —
—/GPP —
—/GPP —
GPP —
Ia/A 69
 C HAPTER 64 • Unstable Lie, Malpresentations, and Malpositions     1133

Evidence Quality and

Management Options Recommendation References
Active Management
Admit to hospital at 37–39 wk; assess daily; if spontaneous conversion to —/GPP —
cephalic presentation occurs, subsequent options are
    Allow patient to return home to await spontaneous labor.
●

    Induce labor.
●

If noncephalic after 36 wk, offer ECV if no contraindications; if successful Ia/A 71

conversion to cephalic is achieved
  ●  Allow patient to return home to await spontaneous labor. —/GPP —
  ●  Perform stabilizing induction between 38 and 39 wk. III/B 47
If ECV fails or version is contraindicated, cesarean section is necessary. Ia/A 72
Labor and Delivery (See Fig. 64–7)
Confirm diagnosis by examination ± ultrasound examination. —/GPP —
First Stage of Labor
If cord presentation or prolapse, cesarean section is necessary. —/GPP —
If no cord presentation —/GPP —
  ●  For ECV if membranes are intact and allow to labor if successful.
  ●  Otherwise perform cesarean section.
Second Stage of Labor
Confirm diagnosis by examination ± ultrasound examination. —/GPP —
If membranes are ruptured, perform cesarean section. —/GPP —
If membranes are not ruptured —/GPP —
  ●  For ECV or internal version* and vaginal delivery if successful.
  ●  If version is unsuccessful, cesarean section is necessary.

* The use of internal podalic version should be limited to the obstetrician with experience with the technique and when fetopelvic disproportion is not
suspected.
ECV, external cephalic version; GPP, good practice point.

Malpresentation prolapse be diagnosed, with the woman forewarned of this

Prenatal
Once an identifiable specific cause for the malpresentation
has been diagnosed if present, such as polyhydramnios, a
distended urinary bladder or a pelvic ovarian cyst, treatment
of the cause may be indicated. For those cases without iden-
tifiable cause, there are no recognized and universally
accepted procedures to use for correcting a fetal brow or
face presentation. In view of the increased risk of cord pre-
sentation and thus cord prolapse with brow presentation, the
woman should be advised of early admission when labor
starts or membrane rupture occurs.
As with unstable lie, admission from 39 weeks’ gestation
should be considered for this reason, although there is little
objective evidence to support this recommendation. If deliv-
ery at this gestation is indicated for other reasons, planned
cesarean section without recourse to labor may be safer than
inducing labor if there is a high presenting fetal part. The
alternative is labor induction with either local prostaglandins
or intravenous oxytocin, with low amniotomy once contrac-
tions are established and the fetal head is engaged or fixed
in the pelvic brim. Preparation should have been made to
allow for rapid cesarean section should cord presentation or
possibility.
Intrapartum
Labor management is the same as for a vertex presentation,
assuming routine maternal and fetal observations are satis-
factory and progress in labor is maintained. Many brow
presentations convert to a face or vertex, and the majority
of face presentations present as mentoanterior. Oxytocin
augmentation is acceptable if uterine contractions are inad-
equate, but caution should always be shown because labor
may become obstructed with dire consequences if left unat-
tended. If progress in labor is slow, resort to cesarean section
may be a wiser option. Figure 64–9 illustrates the manage-
ment options.
Once full dilation is reached with a brow presentation,
spontaneous delivery will not follow unless the fetus is very
small or the pelvis is unusually capacious. Providing the
assessment of the pelvis indicates that there is no evidence
of absolute disproportion, the presentation can be converted
with rotational forceps to face or vertex, whichever proves
to be the easier, and then delivered. Some have advised the
use of the ventouse in this situation, but this requires the cup
1134    S ECTION S IX • Prenatal—General

Vaginal examination

Cord presentation No cord presentation

Identify cause of
malpresentation

Anatomical No anatomical
obstruction obstruction

Labor to full dilatation

Face presentation Brow presentation

Cesarean Spontaneous Instrumental delivery Cesarean Convert to face or

section vaginal as mentoanterior section vertex and FIGURE 64–9 
delivery instrumental delivery Algorithm for the intrapartum management
of face and brow malpresentation.

to be applied behind the bregma and this is unlikely to be
possible in the majority of cases (see Chapter 72). The
majority view is that unless the head is engaged in the pelvis
at the start of vaginal manipulations, delivery by cesarean
section is recommended.
With a face presentation, vaginal delivery should be antic-
ipated if the head is engaged, with the delivery occurring
spontaneously or assisted with forceps. The head should be
in a mentoanterior position at the delivery, corrected by
forceps rotation if necessary (see Chapter 72). The ventouse
has no place in the management of a face presentation. Thus,
cesarean section may be necessary if the obstetrician does
not have the necessary skills to conduct a rotational forceps
delivery.

SUMMARY OF MANAGEMENT OPTIONS

Face and Brow Presentation

Evidence Quality and
Management Options Recommendation References

Prenatal

Confirm diagnosis—examination; ultrasound. —/GPP —

Assess for causal factors. —/GPP —
Interventions
    Perform cesarean section if arrested progress in labor.
● —/GPP —
    Offer cesarean section as an alternative to labor.
● —/GPP —

Labor and Delivery (See Fig. 64–9)

First Stage of Labor

Establish diagnosis by vaginal examination ± ultrasound. —/GPP —
 C HAPTER 64 • Unstable Lie, Malpresentations, and Malpositions     1135

Evidence Quality and

Management Options Recommendation References
Prenatal
Brow Presentation —/GPP —
Allow labor to progress with careful monitoring of progress.
If spontaneous conversion to face or vertex, anticipate
spontaneous vaginal delivery.
Perform assisted vaginal delivery.
Offer cesarean section if arrested progress in labor.
Offer cesarean section if pelvic disproportion is suspected.
Face Presentation —/GPP —
If mentoanterior, allow labor to proceed anticipating vaginal
delivery.
Offer cesarean section if mentoposterior or if pelvic
disproportion is suspected.
Second Stage of Labor
Persistent Brow Presentation —/GPP —
Rotate and convert to vertex or face and deliver.
Recommend cesarean section if pelvic disproportion is
suspected.
Face Presentation —/GPP —
Spontaneous delivery as mentoanterior with adequate
episiotomy.
Rotate to mentoanterior and deliver.
Recommend cesarean section if pelvic disproportion is
suspected.

GPP, good practice point.

Malposition There is no indication that this strategy improves labor

Prenatal
There is probably little benefit from trying to alter an occipi-
toposterior position diagnosed during the antenatal period
because the majority of cases correct themselves before or
after labor starts. There may be some virtue in advising the
woman that (1) her membranes may rupture prior to the
onset of contractions, (2) labor may be more uncomfortable
and possibly more prolonged, and (3) there is a greater
chance of requiring an instrumental delivery or cesarean
section, compared with an occipitoanterior position. Some
women say that they find difficult labor easier to cope with
if forewarned and they may be more inclined to choose a
regional anesthetic early in labor. Conversely, many occipi-
toposterior positions will spontaneously correct to occipito-
anterior during labor, in which case anxiety will have been
outcome, however.69
Intrapartum
When the diagnosis of malposition is made early in labor,
as much information as possible should be gathered about
the fetal position, including (1) the amount of head palpable
per abdomen, (2) the degree of deflexion and asynclitism,
(3) the amount of molding and caput formation, (4) the level
of the presenting part in relation to the ischial spines, and
(5) maternal pelvis size and shape. Issues relating to fetal
well-being including fetal heart rate pattern and the state of
the liquor should also be taken into account, as with all
labors.
Options at this point are as illustrated in the algorithm
(Fig. 64–10) and include
● No specific action if acceptable progress is being made.

generated to no purpose, but it may increase the likelihood ● Providing oxytocin augmentation if uterine contractions

of a maternal request for delivery by antepartum cesarean are incoordinate, infrequent, or of poor quality.
section. Some have suggested the patient adopts a variety of ● Encouraging the patient to lie on the same side as the fetal

positions to encourage rotation of the fetus. An analysis of back.70

the literature, concentrating on the use of the maternal ● Abandoning labor in favor of cesarean section.

hands-knees position during the antenatal and intrapartum Once the second stage of labor has been reached, spon-
periods, concluded that this position compared with others taneous delivery in the occipitoposterior position may result,
resulted in a short-term reversion to an anterior position. or spontaneous rotation may still occur with delivery
1136    S ECTION S IX • Prenatal—General

Occipitoposterior position

Non-progressive 2nd stage

1st stage

Consider different
maternal positions or Non-progressive Progressive
oxytocin infusion 2nd stage 2nd stage

Persistent Deep transverse

occipitoposterior arrest
position

Consider oxytocin
augmentation

Cesarean Deliver as Rotate to Cesarean Spontaneous

section occipitoposterior occipitoanterior section vaginal FIGURE 64–10 
and deliver delivery Algorithm for the intrapartum management of
malposition of the fetal head.

occipitoanterior. Alternatively, delivery may be delayed
by a persistence of the occipitoposterior position or incom-
plete rotation to a deep transverse arrest. It has been sug-
gested that mechanical rotation to the occipitoanterior
position followed by delivery should be avoided if fetal
distress is suspected when delivery by cesarean section is
favored. The decision on management at this stage should
logically be determined by assessing which method of deliv-
ery is most likely to result in an earlier and less traumatic
birth.

SUMMARY OF MANAGEMENT OPTIONS

Malposition
Evidence Quality and
Management Options Recommendation References
Prenatal
No specific managements of proven benefit. Ib/A 69
Labor and Delivery (See Fig. 64–10)
First Stage of Labor
Anticipate possible protracted uncomfortable labor.
  ●  Offer regional analgesia if appropriate. —/GPP —
  ●  Augment with oxytocin infusion. Ib/A 73
Consider cesarean section if secondary arrest. —/GPP —
Second Stage of Labor
Spontaneous rotation and delivery in occipitoanterior position —/GPP —
Spontaneous delivery in occipitoposterior position. —/GPP —
Partial resolution to deep transverse arrest: —/GPP —
  ●  Rotation and delivery in occipitoanterior position.
  ●  Cesarean section.
 C HAPTER 64 • Unstable Lie, Malpresentations, and Malpositions     1137

Evidence Quality and

Management Options Recommendation References
Persistent occipitoposterior position: —/GPP —
    Oxytocin augmentation to achieve a spontaneous
●

delivery.
    Assisted delivery in occipitoposterior position.
●

    Rotation to occipitoanterior position and delivery.

●

    Cesarean section.
●

GPP, good practice point.

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