LIE,

PRESENTATION, ATTITUDE,
AND POSITION OF FETUS
Bagian Obstetri & Ginekologi
Fakultas Kedokteran Universitas Diponegoro
RSUP Dr. Kariadi Semarang

Fetal Orienta+on
Fetal orienta+on rela+ve to the maternal pelvis
Described in terms of :

lie
presenta+on,
a8tude
posi+on.

At the onset of labor, the posi+on of the fetus with respect to

the birth canal is cri+cal to the route of delivery

Fetal Orienta+on
Diagnosis of Fetal Presenta+on and Posi+on :

abdominal palpa+on
vaginal examina+on
ausculta+on,
sonography
Occasionally plain radiographs, computed tomography, or
magne+c resonance imaging may be used.

Abdominal Palpa+on Leopold

Maneuvers

L-I

L-II

L-III

L-IV

Vaginal Examina+on

Locating the sagittal suture

Differentiating the fontanels

Fetal Lie.
The lie is the rela+on of the long

axis of the fetus to that of the

mother, and is either longitudinal
or transverse.
oblique lie : the fetal and the
maternal axes may cross at a 45-
degree angle
Longitudinal : greater than 99
percent
Transverse : predisposing
factors include multiparity,
placenta previa, hydramnios,
and uterine anomalies

Fetal Presenta+on.
The presenting part is that portion of the fetal body
that is either foremost within the birth canal or in
closest proximity to it.
Cephalic
breech
Shoulder
Compound
Face
Brow

TYPES OF CEPHALIC
PRESENTATION.
classied according to the rela>onship between the head and
body of the fetus

(A)vertex, (B) sinciput, (C) brow, and (D) face presentations.

BREECH PRESENTATION.
The three general congura>ons of breech presenta>on :
frank
complete
footling presenta>ons

When the buIocks of the fetus enter the pelvis before the
head, the presenta+on is breech

BREECH PRESENTATION.

Fetal ABtude or Posture.

In the later months of pregnancy the fetus assumes a
characteristic posture described as attitude or
habitus
the fetus forms an ovoid mass that corresponds

roughly to the shape of the uterine cavity.

The fetus becomes folded or bent upon itself in such
a manner that the back becomes markedly convex;
the head is sharply flexed so that the chin is almost
in contact with the chest

Fetal ABtude or Posture.

Fetal Posi+on.
Position refers to the relationship of an arbitrarily

chosen portion of the fetal presenting part to the right

or left side of the maternal birth canal

Accordingly, with each presentation there may be

two positions, right or left

there are :
left and right occipital
left and right mental
left and right sacral presentations

Varieties of Presentations and

Positions.

Longitudinal lie. Vertex

presentation

LeL occiput anterior (LOA).

LeL occiput posterior (LOP).

Longitudinal lie. Vertex

presentation.

Right occiput posterior (ROP).

Right occiput transverse (ROT).

Longitudinal lie

Vertex Presenta>on
Right occiput posterior (ROP).

Breech Presenta>on
LeL Sacrum Posterior (ROP).

Transverse lie

The shoulder
of
the fetus is to
the mother's
right, and the
back is
posterior.

Right Acromiodorsoposterior (RADP)

MALPOSITION &
MALPRESENTATION
Department of Obstetrics Gynecology
Diponegoro University / Kariadi Hospital

TOPIC OVERVIEW
Abnormal lie, malpresentation and malposition

Malposition and its management

OccipitoPosterior
OccipitoTransverse

Malpresentation and its management

Breech
Face
brow
Shoulder
compound

MALPOSITION
Occipito posterior position
Deep transverse arrest

Malposition
It is the vertex position where the occiput is placed
posteriorly over the sacro-ilical joint or directly over the
sacrum, it is called an occipito-posterior position.

When the occiput is placed over the right sacroiliac joint,

the position is called right occipito posterior (R.O.P)
position and when placed over the left sacro-iliac joint, is
called left occipito posterior (L.O.P) position.

When it points towards the sacrum it is called direct

occipito posterior position.

Occipito-posterior
position
Occipito-posterior position is an abnormal position of the vertex rather than an
abnormal presentation.

Occurs in approximately 10% of labours.

A persistent occipito-posterior position results from a failure of internal rotation

prior to birth.

Occurs in 5% of the births.

ROP is five times more common than LOP

Occipito-posterior
position

Causes
The direct cause is often unknown. But the following
are the responsible factors:

Shape of the pelvic inlet: associated with either an

anthropoid or android pelvis.

Fetal factors: Marked deflexion of fetal head.

Uterine factors: Abnormal uterine contraction

Abdominal examination
Listen to the mother: Complain of backache and she may feel that
her babys bottom is very high up against her ribs.
Inspection:

Palpation:

Abdomen looks flat, below

the umbilicus.

Fetal limbs are felt more easily

near midline on either side.

Fetal back is felt far away from

midline on flank.

Anterior shoulder lies far away

from midline.

Head is not engaged.

Cephalic prominence is not felt

so much prominent

Presence of saucer
shaped depression.

The outline created by

high, unengaged head can
look like a full bladder

Most common cause of non engagement in a primigravida at

term.

Abdominal examination

Comparison of abdominal contour in (A) posterior and (B) anterior

positions of the occiput

Abdominal examination
Auscultation
The fetal back is not well
flexed so chest is thrust
forward, therefore the
fetal heart can be heard
in the midline.
Heart rate may be heard
more easily at the flank
on the same side as the
back.

Vaginal examination
Elongated bag of
membranes
Sagittal suture occupies
any of the oblique
diameters of pelvis.
Posterior fontanelle is felt
near the sacro-iliac joint
Anterior fontanelle is felt
more easily

In late labour, the diagnosis is often difficult because of caput formation.

In such cases, the ear is to be located and the unfolded pinna points towards the
occiput.

Fate of OPP
OPP

Engaging diameter :- occipito-frontal

11.5cm or sub-occipitofrontal 10cm.

Unfavorable (10%)

Favorable (90%)
3/8th rotation
occipit comes under
symphysis pubis (rt/
lt occipito anterior)
Normal vaginal delivery

Mild deflexion Moderate

deflexion
Occiput rotate
by 1/8th circle
Deep
transvers
e arrest

Severe
deflexion

Non-rotation Occiput rotate

posteriorly by
th
1/8
Oblique
POPP/
posterior
occipito-sacral
arrest
position
Face to pubis

Arrest

Mechanism of labour
Head engages through right oblique diameter in ROP and
left oblique diameter in LOP.

The engaging transverse diameter of head is biparietal

(9.5 cm) and that of AP diameter is either SOF (10 cm)
or OF (11.5 cm).

Because of deflexion engagement is delayed.

Mechanism of labour cont

Lie: longitudinal
The attitude of the head is deflexed
Presentation: vertex
Position: Right occipitoposterior
Denominator: Occiput
Presenting part: Middle or anterior area of left
parietal bone

The OF diameter 11.5 cm lies in the right oblique

diameter of the pelvic brim. The occiput points to the
right sacroiliac joint and the sinciput to the left
iliopectineal eminence.

Mechanism of labour cont

Flexion: Descent takes place with increasing flexion. The occiput
becomes the leading part.

Internal rotation of head: Occiput reaches pelvic floor first and

rotates forwards 3/8th of a circle along a right side of pelvis to lie
under the symphysis pubis. The shoulders follow, turning 2/8th of
a circle from left to right oblique diameter.

Crowning: Occiput escapes under the symphysis pubis and the

head is crowned.

Extension: Sinciput, face and chin sweep perineum and head is

born by a movement of extension.

Mechanism of labour cont

Restitution: Occiput turns 1/8th of circle to the right.
Internal rotation of shoulders: Shoulders enter the pelvis in right
oblique diameter; anterior shoulder reaches pelvic floor first
and rotates forwards 1/8th of circle to lie under the symphysis
pubis.

External rotation of head: Occiput turns a further 1/8 of a circle

to the right.

Lateral flexion: Anterior shoulder escapes under the symphysis

pubis, posterior shoulder sweeps perineum and body is born by
a movement of lateral flexion.

Mechanism of labour in right occipito posterior

diameter

Mechanism of face to pubis delivery

Further descent occurs until the root of nose hinges under
symphysis pubis.

Flexion occurs releasing successively the brow, vertex and

occiput out of the stretched perineum and then the face is born
by extension.

Restitution: Head moves 1/8th of circle in opposite direction of

internal rotation thus turning the face to look towards the
mothers left thigh in ROP and right thigh in LOP.

External rotation: Occiput further rotates to the same direction

of restitution to 1/8th of a circle placing finally face looking
directly towards the left thigh in ROP and the right thigh in LOP.

Persistent Occipito posterior

It is an abnormal mechanism of the occipito
posterior position where there is malrotation of the
occiput posteriorly towards the sacral hollow.

Delivery may occur spontaneously as face to pubis

but arrest may occur in this position and is called
occipito sacral arrest

Cause: Failure of flexion

Delivery of head in a persistent

occipitoposterior position

Allowing the sinciput to escape as far as the glabella

and the occiput sweeps the perineum, sinciput held
back to maintain flexion

Delivery of head in a persistent

occipitoposterior position

Grasping the head to bring the face down from under

the symphysis pubis and Extension of the head

Upward moulding (dotted line) following

persistent occipito posterior position

Deep transverse arrest

The head is deep into the cavity, the sagittal suture is
placed in the transverse bipsinous diameter and
there is no prognosis in descent of the head even
after -1 hour following full dilatation of cervix.

May be end result of incomplete anterior rotation of

the oblique OPP, or it may be due to non rotation of
the commonly primary occipito transverse position
of normal mechanism of labour.

DEEP TRANSVERSE ARREST

POSISI OKSIPITALIS POSTERIOR

Deep transverse arrest cont

Causes:
Faulty pelvic architecture
Prominent ischial spine,
Flat sacrum and convergent side walls,
Deflexion of head,
Weak uterine contraction,
Laxity of the pelvic floor muscles.
Diagnosis
Head is engaged
Sagittal suture lies in transverse bispinous diameter,
Anterior fontanelle is palpable,
Faulty pelvic architecture may be detected.

Deep transverse arrest cont

Management:
Vaginal delivery is found safe.

Ventouse
Manual rotation and application of forceps
Forceps rotation and delivery with Keilland in
hands of an expert.

Vaginal delivery is not safe: caesarean section.

Craniotomy in dead pelvis.

Diagnosis of OP position
First stage of labour:

Signs are those of any posterior position of occiput, namely a deflexed

head and the fetal heart heard in the flank or in the midline.

Descent is slow

Second stage of labour:

Delay is common.
Vaginal examination: Anterior fontanelle is felt behind symphysis pubis. If
the pinna of the ear is felt pointing towards the mothers sacrum, this
indicates a posterior position.

Diagnosis of OP position cont..

The birth

Sinciput will first emerge from under symphysis pubis as

far as the root of the nose and flexion should be
maintained by restraining it from escaping further than
the glabella, allowing the occiput to sweep the perineum
and be born.

Extends the head by grasping it and bringing the face

down from under the symphysis pubis.

Perineal trauma and PPH are common. An episiotomy

may be required, owing to the larger presenting diameter.

Mode of delivery
Long anterior rotation of the occiput: Spontaneous or aided
vaginal delivery usually occurs (90%)

Short posterior rotation: Spontaneous or aided vaginal delivery

may occur as face to pubis.

Non-rotation or short anterior rotation: Spontaneous vaginal

delivery is unlikely except in favourable circumstances.

Moulding: The characteristic moulding of head occurs in face to

pubis delivery. There is compression of the occipito-frontal
diameter with elongation of the vault at right angle to it. The
frontal bones are displaced beneath the parietal bones.

Complications
Obstructed labour
Cerebral hemorrhage
Maternal trauma
Neonatal trauma
Cord prolapse

References
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2009

2. Dutta DC. Textbook of obstetrics. 6th edition.

Calcutta:New central book agency;2004

3. Pillitteri A. Maternal and child health nursing. Care of

the childbearing and childrearing family. Sixth edition.
Philadelphia; Lippincott Williams & Wilkins: 2010.

4. Cunningham, Leveno, Bloom. Williams obstetrics. 23rd

edition. United states of
companies: 2010.

America; Mcgraw Hill