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What is presentation and malpresentation?

‘Presentation’ describes how your baby is facing down the birth canal. The ‘presenting part’ is the part of your baby’s body that is against the cervix.

The ideal presentation is head-first, where the crown (top) of the baby’s head is against the cervix, and the chin tucked is into the baby’s chest. This is called ‘vertex presentation’.

If your baby is in any other position, it’s called ‘malpresentation’. Malpresentation can mean your baby’s face, brow, buttocks, foot, back, shoulder, arms or legs or the umbilical cord are against the cervix.

It’s safest for your baby’s head to come out first. If any other body part enters the birth canal first, there is a higher risk of complications for both you and your baby. Malpresentation increases the chance that you will have a more complex vaginal birth or need a caesarean.

If my baby is not head-first, what position could they be in?

Malpresentation is caused by your baby’s position (‘lie’). There are different types of malpresentation.

Breech presentation

This is when your baby is lying with their bottom or feet facing down. Sometimes, one foot may enter the birth canal first (called a ‘footling presentation’).

Breech presentation is the most common type of malpresentation.

Face presentation

This is when your baby is head-first, but stretching their neck, so their face is pressed against the cervix.

Transverse lie

This is when your baby is lying sideways. Their back, shoulders, arms or legs may be first to enter the birth canal.

Oblique lie

This is when your baby is lying diagonally. No particular part of their body is against the cervix.

Unstable lie

This is when your baby continually changes their position after 36 weeks of pregnancy.

Cord presentation

This is when the umbilical cord is against the cervix, between your baby and the birth canal. It can happen in any situation where your baby’s presenting part is not sitting snugly in your pelvis. It can become a medical emergency if it leads to cord prolapse (when the cord comes down the birth canal before your baby, potentially reducing blood flow to your baby).

What is malposition?

‘Position’ refers to which direction your baby is facing.

If your baby is head-first, the best position for labour is with their face is towards your back.

If your baby is head-first, but facing the front of your body (posterior position) or facing your side (transverse or lateral position) this is called malposition. It means your labour may take longer and you might feel more pain in your back. Babies who are malpositioned may move into a better position before or during labour.

What causes malpresentation?

Often, no cause is found, but malpresentation is more likely:

• a low-lying placenta
• too much or too little amniotic fluid
• an abnormally shaped uterus or problems with the uterus, such as large
• many previous pregnancies, making the muscles of the uterus less stable
• carrying twins or more

Often, no cause is found.

What is the chance I will have a malpresentation?

Many babies maintain a breech position during pregnancy. They usually turn head-first as pregnancy progresses. More than 9 in 10 babies in Australia are in a head-first position at birth.

You are more likely to have a malpresentation if:

• this is your first baby
• you've had a breech presentation in a past pregnancy
• you go into labour prematurely

How is malpresentation diagnosed?

Your doctor or midwife can diagnose malpresentation by examining your abdomen and feeling the baby’s position. If they aren’t sure, it can be confirmed with an ultrasound.

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Can my baby’s position be changed?

If your baby is still in a breech position when you are 36 weeks pregnant, it’s less likely that they will turn head-first on their own. Your obstetrician may recommend a procedure called an called external cephalic version (ECV) to try and gently turn your baby to a head-first position.

Some people try different postures, or moxibustion to correct malpresentation, but there is limited evidence that this work. Although if moxibustion is done before 37 weeks of pregnancy there is some evidence to suggest that this may reduce the chance of your baby being breech at birth. It’s a good idea to talk to your maternity care provider before trying alternative therapies to understand what is right for you.

Will I need a caesarean if my baby has a malpresentation?

Most babies with a malpresentation close to birth are born by caesarean. If your baby is breech, you may be able to have a vaginal birth, but it’s important that you are cared for in a hospital that can offer you and your baby specialised care. Ask your doctor or midwife for advice.

If your baby is breech, an elective (planned) caesarean is safer for your baby than a vaginal birth in the short term. However, in the longer term their health will be similar, on average, regardless of how they were born.

A vaginal birth is safer for you than an elective caesarean. However, about 4 in 10 people planning a vaginal breech birth end up needing an emergency caesarean. If this happens to you, the risk of complications will be higher than an elective caesarean.

Your doctor can talk to you about your options. Whether it’s safe for you to try a vaginal birth will depend on many factors, such as:

• your baby’s size
• the position of your baby
• whether you’ve had a caesarean in the past
• the expertise of your doctor and the services available at your hospital

What are the risks if I have my baby when it’s not head-first?

This will vary based on your individual circumstance. Talk to your maternity care provider about what your baby’s position means for your pregnancy, labour and birth. This will help you make informed decision that are right for you.

If your waters break when your baby is not head-first, there is a risk of cord prolapse. This is a medical emergency.

Vaginal breech birth

Risks to your baby can include:

• fractures, dislocations or other injuries
• bleeding in your baby’s brain
• low Apgar scores
• their head getting stuck – this is a medical emergency

Caesarean

Risks to you include:

• excessive blood loss
• infection in the wound
• problems with the anaesthetic
• damage to other organs nearby, such as your bladder
• a higher chance of complications in future pregnancies
• a longer recovery time than after a vaginal birth

Risks to your baby include:

• trouble with breathing — this is temporary
• getting a small cut during the surgery by accident

Will I have a malpresentation in my future pregnancies?

If you had a malpresentation in one pregnancy, you have a higher chance of it happening again. If you’re worried, it may help to talk to your doctor or midwife.