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Vertex Position: What It Is, Why It's Important, and How to Get There

Jamie Grill / Getty Images

What Is the Vertex Position?

• Why It's Important

When the Vertex Position Usually Occurs

• How to Get Baby in This Position

Options if Baby Is Not in the Vertex Position

While you are pregnant, you may hear your healthcare provider frequently refer to the position or presentation of your baby, particularly as you get closer to your due date . What they are referring to is which part of your baby is presenting first—or which part is at the lower end of your womb or the pelvic inlet.

Consequently, when they tell you that your baby's head is down, that likely means they are in the vertex position (or another cephalic position). This type of presentation is the most common presentation in the third trimester. Here is what you need to know about the vertex position including how you might get your baby into that position before you go into labor .

The vertex position is a medical term that means the fetus has its head down in the maternal pelvis and the occipital (back) portion of the fetal skull is in the lowest position or presenting, explains Jill Purdie, MD, an OB/GYN and medical director at Northside Women’s Specialists , which is part of Pediatrix Medical Group.

When a baby is in the vertex position, their head is in the down position in the pelvis in preparation for a vaginal birth, adds Shaghayegh DeNoble, MD, FACOG , a board-certified gynecologist and a fellowship-trained minimally invasive gynecologic surgeon. "More specifically, the fetus’s chin is tucked to the chest so that the back of the head is presenting first."

Why the Vertex Position Is Important

When it comes to labor and delivery, the vertex position is the ideal position for a vaginal delivery, especially if the baby is in the occiput anterior position—where the back of the baby's head is toward the front of the pregnant person's pelvis, says Dr. DeNoble.

"[This] is the best position for vaginal birth because it is associated with fewer Cesarean sections , faster births, and less painful births," she says. "In this position, the fetus’s skull fits the birth canal best. In the occiput posterior position, the back of the fetus's head is toward the [pregnant person's] spine. This position is usually associated with longer labor and sometimes more painful birth."

Other fetal positions are sometimes less-than-ideal for labor and delivery. According to Dr. DeNoble, they can cause more prolonged labor, fetal distress, and interventions such as vacuum or forceps delivery and Cesarean delivery.

"Another important fact is that positions other than vertex present an increased risk of cord prolapse, which is when the umbilical cord falls into the vaginal canal ahead of the baby," she says. "For example, if the fetus is in the transverse position and the [pregnant person's] water breaks , there is an increased risk of the umbilical cord prolapsing through the cervix into the vaginal canal."

When it comes to your baby's positioning, obstetricians will look to see what part of the fetus is in position to present during vaginal birth. If your baby’s head is down during labor, they will look to see if the back of the head is facing your front or your back as well as whether the back of the head is presenting or rather face or brow, Dr. DeNoble explains.

"These determinations are important during labor, especially if there is consideration to the use of a vacuum or forceps," she says.

According to Dr. Purdie, healthcare providers will begin assessing the position of the baby as early as 32 to 34 weeks of pregnancy. About 75% to 80% of fetuses will be in the vertex presentation by 30 weeks and 96% to 97% by 37 weeks. Approximately 3% to 4% of fetuses will be in a non-cephalic position at term, she adds.

Typically, your provider will perform what is called Leopold maneuvers to determine the position of the baby. "Leopold maneuvers involve the doctor placing their hands on the gravid abdomen in several locations to find the fetal head and buttocks," Dr. Purdie explains.

If your baby is not in the vertex position, the next most common position would be breech, she says. This means that your baby's legs or buttocks are presenting first and the head is up toward the rib cage.

"The fetus may also be transverse," Dr. Purdie says. "The transverse position means the fetus is sideways within the uterus and no part is presenting in the maternal pelvis. In other words, the head is either on the left or right side of the uterus and the fetus goes straight across to the opposite side."

There is even a chance that your baby will be in an oblique position. This means they are at a diagonal within the uterus, Dr. Purdie says. "In this position, either the head or the buttocks can be down, but they are not in the maternal pelvis and instead off to the left or right side."

If your baby's head is not down, your provider will look to see if the buttocks are in the pelvis or one or two feet, Dr. DeNoble adds. "If the baby is laying horizontally, then the doctor needs to know if the back of the baby is facing downwards or upwards since at a Cesarean delivery it can be more difficult to deliver the baby when the back is down."

How to Get Baby Into the Vertex Position

One way you can help ensure that your baby gets into the vertex position is by staying active and walking, Dr. Purdie says. "Since the head is the heaviest part of the fetus, gravity may help move the head around to the lowest position."

If you already know that your baby is in a non-cephalic position and you are getting close to your delivery date, you also can try some techniques to encourage the baby to turn. For instance, Dr. Purdie suggests getting in the knee/chest position for 10 minutes per day. This has been shown to turn the baby around 60% to 70% of the time.

"In this technique, the mother gets on all fours, places her head down on her hands, and leaves her buttock higher than her head," she explains. "Again, we are trying to allow gravity to help us turn the fetus."

You also might consider visiting a chiropractor to try and help turn the fetus. "Most chiropractors will use the Webster technique to encourage the fetus into a cephalic presentation," Dr. Purdie adds.

There also are some home remedies, including using music, heat, ice, and incense to encourage the fetus to turn, she says. "These techniques do not have a lot of scientific data to support them, but they also are not harmful so can be tried without concern."

You also can try the pelvic tilt , where you lay on your back with your legs bent and your feet on the ground, suggests Dr. DeNoble. Then, you tilt your pelvis up into a bridge position and stay in this position for 10 minutes. She suggests doing this several times a day, ideally when your baby is most active.

"Another technique that has helped some women is to place headphones low down on the abdomen near the pubic bone to encourage the baby to turn toward the sound," Dr. DeNoble adds. "A cold bag of vegetables can be placed at the top of the uterus near the baby’s head and something warm over the lower part of the uterus to encourage the baby to turn toward the warmth. [And] acupuncture has also been used to help turn a baby into a vertex position."

If you are at term and your baby is not in the vertex position (or some type of cephalic presentation), you may want to discuss the option of an external cephalic version (ECV), suggests Dr. Purdie. This is a procedure done in the hospital where your healthcare provider will attempt to manually rotate your baby into the cephalic presentation.

"There are some risks associated with this and not every pregnant person is a candidate, so the details should be discussed with your physician," she says. "If despite interventions, the fetus remains in a non-cephalic position, most physicians will recommend a C-section for delivery."

Keep in mind that there are increased risks for your baby associated with a vaginal breech delivery. Current guidelines by the American College of Obstetricians and Gynecologists recommend a C-section in this situation, Dr. Purdie says.

"Once a pregnant person is in labor, it would be too late for the baby to get in cephalic presentation," she adds.

A Word From Verywell

If your baby is not yet in the vertex position, try not to worry too much. The majority of babies move into either the vertex position or another cephalic presentation before they are born. Until then, focus on staying active, getting plenty of rest, and taking care of yourself.

If you are concerned, talk to your provider about different options for getting your baby to move into the vertex position. They can let you know which tips and techniques might be right for your situation.

American College of Obstetrics and Gynecology. Obstetrics data definitions .

National Library of Medicine. Vaginal delivery .

Sayed Ahmed WA, Hamdy MA. Optimal management of umbilical cord prolapse .  Int J Womens Health . 2018;10:459-465. Published 2018 Aug 21. doi:10.2147/IJWH.S130879

Hjartardóttir H, Lund SH, Benediktsdóttir S, Geirsson RT, Eggebø TM. When does fetal head rotation occur in spontaneous labor at term: results of an ultrasound-based longitudinal study in nulliparous women .  Am J Obstet Gynecol . 2021;224(5):514.e1-514.e9. doi:10.1016/j.ajog.2020.10.054

Management of breech presentation: green-top guideline no. 20b .  BJOG: Int J Obstet Gy . 2017;124(7):e151-e177. doi:10.1111/1471-0528.14465

Kenfack B, Ateudjieu J, Ymele FF, Tebeu PM, Dohbit JS, Mbu RE. Does the advice to assume the knee-chest position at the 36th to 37th weeks of gestation reduce the incidence of breech presentation at delivery?   Clinics in Mother and Child Health . 2012;9:1-5. doi:10.4303/cmch/C120601

Cohain JS. Turning breech babies after 34 weeks: the if, how, & when of turning breech babies .  Midwifery Today Int Midwife . 2007;(83):18-65.

American College of Obstetrics and Gynecology. If your baby is breech .

By Sherri Gordon Sherri Gordon, CLC is a published author, certified professional life coach, and bullying prevention expert. 

Fetal Presentation, Position, and Lie (Including Breech Presentation)

• Variations in Fetal Position and Presentation |

During pregnancy, the fetus can be positioned in many different ways inside the mother's uterus. The fetus may be head up or down or facing the mother's back or front. At first, the fetus can move around easily or shift position as the mother moves. Toward the end of the pregnancy the fetus is larger, has less room to move, and stays in one position. How the fetus is positioned has an important effect on delivery and, for certain positions, a cesarean delivery is necessary. There are medical terms that describe precisely how the fetus is positioned, and identifying the fetal position helps doctors to anticipate potential difficulties during labor and delivery.

Presentation refers to the part of the fetus’s body that leads the way out through the birth canal (called the presenting part). Usually, the head leads the way, but sometimes the buttocks (breech presentation), shoulder, or face leads the way.

Position refers to whether the fetus is facing backward (occiput anterior) or forward (occiput posterior). The occiput is a bone at the back of the baby's head. Therefore, facing backward is called occiput anterior (facing the mother’s back and facing down when the mother lies on her back). Facing forward is called occiput posterior (facing toward the mother's pubic bone and facing up when the mother lies on her back).

Lie refers to the angle of the fetus in relation to the mother and the uterus. Up-and-down (with the baby's spine parallel to mother's spine, called longitudinal) is normal, but sometimes the lie is sideways (transverse) or at an angle (oblique).

For these aspects of fetal positioning, the combination that is the most common, safest, and easiest for the mother to deliver is the following:

Head first (called vertex or cephalic presentation)

Facing backward (occiput anterior position)

Spine parallel to mother's spine (longitudinal lie)

Neck bent forward with chin tucked

Arms folded across the chest

If the fetus is in a different position, lie, or presentation, labor may be more difficult, and a normal vaginal delivery may not be possible.

Variations in fetal presentation, position, or lie may occur when

The fetus is too large for the mother's pelvis (fetopelvic disproportion).

The uterus is abnormally shaped or contains growths such as fibroids .

The fetus has a birth defect .

There is more than one fetus (multiple gestation).

Position and Presentation of the Fetus

Variations in Fetal Position and Presentation

Some variations in position and presentation that make delivery difficult occur frequently.

Occiput posterior position

In occiput posterior position (sometimes called sunny-side up), the fetus is head first (vertex presentation) but is facing forward (toward the mother's pubic bone—that is, facing up when the mother lies on her back). This is a very common position that is not abnormal, but it makes delivery more difficult than when the fetus is in the occiput anterior position (facing toward the mother's spine—that is facing down when the mother lies on her back).

When a fetus faces up, the neck is often straightened rather than bent,which requires more room for the head to pass through the birth canal. Delivery assisted by a vacuum device or forceps or cesarean delivery may be necessary.

Breech presentation

In breech presentation, the baby's buttocks or sometimes the feet are positioned to deliver first (before the head).

When delivered vaginally, babies that present buttocks first are more at risk of injury or even death than those that present head first.

The reason for the risks to babies in breech presentation is that the baby's hips and buttocks are not as wide as the head. Therefore, when the hips and buttocks pass through the cervix first, the passageway may not be wide enough for the head to pass through. In addition, when the head follows the buttocks, the neck may be bent slightly backwards. The neck being bent backward increases the width required for delivery as compared to when the head is angled forward with the chin tucked, which is the position that is easiest for delivery. Thus, the baby’s body may be delivered and then the head may get caught and not be able to pass through the birth canal. When the baby’s head is caught, this puts pressure on the umbilical cord in the birth canal, so that very little oxygen can reach the baby. Brain damage due to lack of oxygen is more common among breech babies than among those presenting head first.

In a first delivery, these problems may occur more frequently because a woman’s tissues have not been stretched by previous deliveries. Because of risk of injury or even death to the baby, cesarean delivery is preferred when the fetus is in breech presentation, unless the doctor is very experienced with and skilled at delivering breech babies or there is not an adequate facility or equipment to safely perform a cesarean delivery.

Breech presentation is more likely to occur in the following circumstances:

Labor starts too soon (preterm labor).

The uterus is abnormally shaped or contains abnormal growths such as fibroids .

Other presentations

In face presentation, the baby's neck arches back so that the face presents first rather than the top of the head.

In brow presentation, the neck is moderately arched so that the brow presents first.

Usually, fetuses do not stay in a face or brow presentation. These presentations often change to a vertex (top of the head) presentation before or during labor. If they do not, a cesarean delivery is usually recommended.

In transverse lie, the fetus lies horizontally across the birth canal and presents shoulder first. A cesarean delivery is done, unless the fetus is the second in a set of twins. In such a case, the fetus may be turned to be delivered through the vagina.

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Vertex Presentation: How does it affect your labor & delivery?

Medically Reviewed by: Dr. Veena Shinde (M.D, D.G.O,  PG – Assisted Reproductive Technology (ART) from Warick, UK) Mumbai, India

• >> Post Created: February 11, 2022
• >> Last Updated: June 10, 2024

Vertex Position - Table of Contents

As you approach the due date for your baby’s delivery, the excitement and apprehensions are at their peak! What probably adds to the anxieties are the medical terms describing the baby, its ‘position’ and ‘presentation.’ Let’s strike that out from the list now!

In simple words, ‘ position ’ of the baby is always in reference to the mother ; on what side of the mother’s pelvis does the baby lean more (left or right) and if the baby is facing the mother’s spine or belly (anterior or posterior) – for eg.: Left Occiput Anterior , Right Occiput Anterior , Right Occiput Posterior and so on.

On the other hand, ‘ presentation’ is the body part of baby (head, shoulder, feet, and buttocks) that will enter the mother’s pelvic region first at the beginning of labor.

As ‘ presentation’ depends on the ‘ position’ of the baby, the terms cannot be used interchangeably, which is often mistakenly done. If you are told by your doctor that your baby is in a head-down position , which means its head will enter the pelvic region first , then it means the baby is in ‘vertex’ presentation or even sometimes loosely referred to as vertex position of baby though its conceptually incorrect however it means the same.

With this article, we aim to explain how exactly vertex presentation affects your labor and delivery.

Understanding Vertex Presentation

If your baby is in the head-down position by the third trimester, then you are one of the 95% mothers who have a vertex baby or a vertex delivery. When the baby enters the birth canal head first, then the top part of the head is called the ‘vertex.’

In exact medical terms, we give you the definition of vertex presentation by the American College of Obstetrics and Gynecologists (ACOG) – “a fetal presentation where the head is presenting first in the pelvic inlet.”

Besides vertex presentation (also sometimes referred to as vertex position of baby or vertex fetal position also), the other occasional presentations (non-vertex presentations) include –

• Breech – baby’s feet or buttocks are down and first to enter the mother’s pelvic region. Head is near the mother’s ribs
• Transverse – baby’s shoulder, arm or even the trunk are the first to enter the pelvis, as the baby is laying on the side and not in a vertical position 

It is common that babies turn to a particular position (hence, affecting the presentation) by 34 -36 weeks of pregnancy. Nevertheless, some babies have ‘unstable lies’ ; – wherein the baby keeps changing positions towards the end of the pregnancy and not remaining in any one position for long.

Should you be worried if the baby is in vertex presentation?

Absolutely not! The vertex presentation is not only the most common, but also the best for a smooth delivery. In fact, the chances of a vaginal delivery are better if you have a vertex fetal position.

By 36 weeks into pregnancy, about 95% of the babies position themselves to have the vertex presentation. However, if your baby hasn’t come into the vertex fetal position by this time, then you can talk to your doctor about the options.

You may be suggested a cephalic version procedure   also known as the version procedure /external cephalic version (ECV procedure) – which is used to turn the baby/ fetus from a malpresentation – like breech, oblique or transverse (which occur just about 3-4% times) to the cephalic position (head down).

This is how your doctor will try to turn your baby manually by pushing on your belly to get the baby into the vertex presentation. But it is necessary for you to know that this procedure does involve some risk and is successful only 60-70% of the time.

Continue reading below ↓

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Risks of vertex position of baby: can there be any complications for the baby in the vertex presentation.

As discussed above, the vertex fetal position/presentation is the best for labor and delivery, but there can be some complications as the baby makes its way through the birth canal. One such complication can arise if the baby is on the larger side. The baby can face difficulty while passing through the birth canal even if it is in the head-down position because of the size.

Babies who weigh over 9 to 10 pounds are called ‘ macrosomic’ or even referred to as fetal macrosomia , and they are at a higher risk of getting their shoulders stuck in the birth canal during delivery, despite being in the head-down position.

In such cases, to avoid birth trauma for the baby, the American College of Obstetricians and Gynecologists (ACOG) suggests that cesarean deliveries should be limited to estimated fetal weights of at least 11 pounds in women without diabetes and about 9 pounds in women with diabetes.

In case of fetal macrosomia, your doctor will monitor your pregnancy more often and work out a particular birth plan for you subject to your age (mothers age) and size of your baby.

How will I deliver a baby in the vertex fetal position?

Even unborn human babies can astonish you if you observe the way they make their way through the birth canal during delivery.

A vertex baby may be in the optimal position ( head-down first in pelvis) for labor and delivery, but it does its own twisting and turning while passing through the birth canal to fit through. In humans, unlike other mammals, the ratio of the baby’s head to the space in the birth canal is quite limited.

The baby has to flex and turn its head in different positions to fit through and ultimately arrive in this world. And it does so successfully! It is a wonder how they know how to do this so naturally.

And to answer the question ‘how will I deliver a baby in the vertex position?’ – Simply NATURALLY i.e. vaginal delivery. Don’t worry, follow your doctor’s instructions, do your breathing and PUSH.

FAQs to keep ready: How can my doctor help me prepare as I approach my due date?

As your due date nears, apart from bodily discomfort, you may experience nervousness about the big day. Your doctor can help by clearing your doubts and putting you at ease. You can ask them the following questions to understand the process better.

Q1) How will I know if my baby is in vertex fetal position?

A doctor can confidently tell you whether or not your baby is in the vertex presentation. Many medical professionals will be able to determine your baby’s position merely by using their hands; this is called ‘Leopold’s maneuvers.’

However, in case they aren’t very confident about the baby’s position even after this, then an ultrasound can confirm the exact position of the baby.

You can also understand this through belly mapping . You are sure to feel the kicks towards the top of your stomach and head (distinct hard circular feel) towards your pelvis. 

Q2)Is there any risk of my vertex baby turning and changing positions?

Yes, in case of some women, the baby who has a vertex presentation may turn at the last moment.

What may cause this? Women who have extra amniotic fluid (polyhydramnios) have increased chances of a vertex baby turning into a breech baby at the last minute.

Discuss this with your doctor to understand what are the chances this might happen to you and what all you can do to keep the baby in the vertex presentation for delivery.

Q3) Is there need to be worried if my baby has a breech presentation?

Not really! There are loads of exercises which you which can help you get your baby in the right position.

Then there are the ECV (external cephalic version) procedure which can help in changing the position of your baby into the desired vertex position. Speak with your doctor.

Having a baby in breech position just before labor will require you to have a C-section . Let your doctor guide you. But there is nothing to worry about.

Q4) What may cause babies to come into breech position?

A few circumstances may cause the baby to come into breech position even after 36 weeks into pregnancy.

• If you are carrying twins or multiple babies , in which case there is limited space for each baby to move around.
• Low levels of amniotic fluid which restricts the free movement of the baby or even high levels of amniotic fluid that does not permit the baby to remain in any one position.
• If there are abnormalities in the uterus or other conditions like low-lying placenta or large fibroids in the lower part of the uterus.

Chances of breech babies are higher in births that are pre-term as the baby does not get enough time to flip into a head-down position – cephalic position – vertex presentation (vertex position of baby/ vertex fetal position).

Q5) Can a baby turn from breech position to vertex presentation?

Yes, a baby can turn from a breech position to vertex position / vertex fetal position over time with exercises and sometimes through ECV.

If an ultrasound has confirmed you have a breech baby, then you can do the following to turn it to a vertex baby. Try the following –

• Do not underestimate the wonders of daily walks of about 45-60 mins when it comes to bringing your baby in vertex presentation from breech presentation.
• Talk to your doctor about certain exercises that can help turn your baby in the head-down position. Exercises like ‘ high bridge’ or ‘cat and camel’ can help here. We recommend you to learn and try this only in the presence of a professional.
• External Cephalic Version (ECV ) is a way to manually maneuver the baby to vertex presentation. It is done with the help of an ultrasound and generally after 36 weeks into pregnancy. However, it has the success rate of just 50%. Discuss the risks, if any, with your gynecologist before opting for this procedure.

There are a couple of other unscientific methods that may not be safe to try –

• Light : Placing a torch near your vagina may guide the baby toward the light, and hence, get it in the vertex presentation.
• Music : Playing music near your belly’s bottom may urge the baby to move itself in the head-down position.

Q6) What all can I do to ensure I have a healthy delivery?

A healthy delivery requires the mother to be active, eating well, and staying happy. For any apprehensions regarding labor and delivery, do not hesitate to talk to your doctor and clarify your doubts.

Your doctor can help you understand your baby’s position and presentation, and then based on that they can plan your delivery to ensure your baby’s birth will happen in the safest possible way.

Try and maintain a healthy lifestyle which will also help in overall of your child and placenta health .

Key Takeaway

Yes, vertex presentation or vertex position of baby and vertex delivery are very common, normal, safe, and the best for labor and delivery of the baby. There is probability of complications sometimes, but that is only subject to certain conditions that we discussed above.

However, understand that any other baby position is also safe. The only thing with other positions and presentations is that the chances of a cesarean delivery goes up. Nevertheless, know what matters at the end of it all is a happy and healthy baby in your arms!

Happy pregnancy!

Khushboo Kirale

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Vertex Presentation: What It Means for You & Your Baby

By Sitaram Bhartia Team | December 3, 2020 | Maternity | 2020-12-03 13 April 2023

During the course of your pregnancy, you may hear your gynecologist refer to the ‘position’ or ‘presentation’ of your baby. The ‘presentation’ of the baby is the part of the baby that lies at the lower end of the uterus (womb) or is at the entry of the pelvis. 

The ‘position’, in medical terms, indicates in which way the ‘presenting part’ of the baby lies in relation to the mother, i.e. whether it lies in the front, at the back or on the sides.  

“In layman terms, ‘presentation’ and ‘position’ are often used interchangeably,” says Dr. Anita Sabherwal Anand, Obstetrician-Gynecologist at Sitaram Bhartia Hospital in Delhi.

When a doctor says that your baby is in a head down position, it means that your baby is in vertex presentation .

What is vertex position in pregnancy? What is the difference between vertex and cephalic presentation?

In layman terms, the head down position is known as ‘cephalic presentation’ which means that the head of the baby lies towards the mouth of the uterus (cervix) and the buttocks and feet of the baby are located at the top of the uterus. Vertex is the medical term for “crown of head”. Vertex presentation indicates that the crown of the head or vertex of the baby is presenting towards the cervix.

Vertex presentation is the most common presentation observed in the third trimester.

The definition of vertex presentation , according to the American College of Obstetrics and Gynecologists is, “ A fetal presentation where the head is presenting first in the pelvic inlet.”

Is vertex presentation normal?

Yes, the vertex position of the baby is the most appropriate and favourable position to achieve normal delivery .

“About 95% of babies are in vertex presentation (head down) at 36 weeks, while 3-4% may lie in a ‘ breech position ,” says Dr. Anita.

Breech presentation is a non vertex presentation .

A baby is said to be in breech presentation when its feet and buttocks are at the bottom, on the cervix, and the head settles at the top of the uterus.

Should I be worried about a breech presentation?

“There is no need to worry because babies turn throughout pregnancy, “ explains Dr. Anita. 

In the early weeks of pregnancy, because the baby is small, it can lie in any position. As it grows heavier than 1 kg, it usually tumbles down and comes into the head down position. 

What may cause babies to be in the breech position?

There are a few situations that may increase the risk of having a breech baby even after 36 weeks of pregnancy. These are:

• Twins or multiple babies, wherein there is limited space for movement of the babies
• Low levels of amniotic fluid that prevents free movement of babies or very high volume of amniotic fluid that does not allow the baby to settle in a position
• Abnormalities in the uterus, either the presence of low lying placenta or large fibroids in the lower part of the uterus

Breech positions are higher in preterm birth where the baby is small and may not have had enough time to flip.

“Your gynecologist will place her hands on your abdomen and ascertain the baby’s position during your consultations in the third trimester.”

It was in one such consultation that Shilpa Newati found out that her baby was in breech presentation. She was consulting another hospital where her gynecologist advised a cesarean section. But Shilpa remained adamant and decided to get a second opinion. 

“When I came to Sitaram Bhartia Hospital, the gynecologist explained that babies can turn even until the last moment. Since my pregnancy was progressing well she saw no reason to rush into a cesarean section. “

“I was advised to wait and try a few simple techniques that may help the baby turn.”

Can a baby turn from being in breech presentation to vertex presentation ?

Yes. If your baby is in breech position, you could try turning your baby through these methods: 

• Daily walks (45-60 minutes) not only keep the mother fit but also help the baby tumble down into the head down position.
• Exercises like Cat and Camel or High Bridge may help turn the baby. “Be sure to learn these from a physiotherapist who can properly teach you what to do.”
• External Cephalic Version (ECV) is a maneuver to manually turn the baby to vertex presentation . It is usually done after 36 weeks by a gynecologist with the guidance of an ultrasound. ECV has a success rate of about 50% .

There are a few other methods that are not scientifically proven but may be safe to try.

• Torch: Placing a torch near your vagina may help the baby move in the direction of the light.
• Music: Playing music near the bottom of the belly may encourage the baby to move toward the sound of music.

In Shilpa’s case, the baby turned into vertex presentation at 37 weeks and she went on to have a vaginal delivery like she had hoped. 

Watch Shilpa share her story:

In very few instances, the baby may not turn into vertex presentation . In such a situation, a cesarean section may be safer for both mother and baby. 

Come in for a consultation  Please Chat with us on WhatsApp to schedule an appointment.

More Resources:

• Baby’s Head Engaged: Symptoms, Meaning & What You Can Do
• C Section Delivery: 9 Indications Where It May Be Avoidable
• How to Turn Baby’s Head Down Naturally [VIDEO]

This article has been written with and reviewed by Dr. Anita Sabherwal Anand , who has over 20 years of experience in Obstetrics and Gynecology. 

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What to Know About the Vertex Position

When you give birth, your baby usually comes out headfirst, also called the vertex position. In the weeks before you give birth, your baby will move to place their head above your vagina .

Your baby could also try to come out feet -first, bottom-first, or both feet- and bottom-first. This is the breech position and only happens in about 3% to 4% of births. Your baby could also be in transverse position if they’re sideways inside of you. If your baby is in breech position or transverse position, your doctor will talk to you about different options that you have to give birth.

Birth in Vertex Position

Before you give birth, your baby will change positions inside of you. But when labor begins, babies usually move into the vertex position.

They will move farther down to the opening of your vagina . The doctor or  midwife  will instruct you on pushing your baby until their head is almost ready to come out. You'll take long, deep breaths to oxygenate the baby. A slow birth of your baby’s head will also help stretch the skin and muscles around your vagina.

Other Positions Your Baby Can Be In

Breech position. If your baby is still in the breech position at 36 weeks of pregnancy , your doctor may offer you an external cephalic version (ECV), which is where a doctor puts pressure on your uterus to try to turn your baby to a headfirst position. It may be slightly uncomfortable or even painful, but it’s generally a safe way to help your baby reach the vertex position. ECV helps babies get to a headfirst position about 50% of the time.

You shouldn’t have an ECV if you have had recent bleeding from your vagina, if your baby’s heartbeat is abnormal, if your water is broken, or if you’re pregnant with more than one baby.

If ECV doesn’t work, you’ll either have a cesarean section (C-section), which is when a baby is delivered through a cut in the uterus and abdomen , or a vaginal breech birth.

It may not be safe to have a vaginal breech birth if your baby’s feet are under their bottom, your baby is bigger or smaller than average, your baby is in an odd position, you have a low placenta , or you have preeclampsia , which is when you have high blood pressure and damage to organs with pregnancy.

Transverse position. If your baby is laying sideways across your uterus close to the time of delivery, your doctor would offer an ECV or C-section. 

Your doctors may be able to turn your baby to a headfirst position, but if they can’t or you begin labor before they can turn your baby, you’ll most likely have a C-section.

Risks of Breech and Transverse Position

ECV problems. If your baby isn’t in vertex position and your doctor uses ECV to move them, some problems can happen. Your amniotic sac, or the part that holds liquid during pregnancy, can break early, your baby’s heart rate may change, your placenta may pull apart from your uterus, or you could go into labor too early.

Your baby may also move back into a breech position once your doctor moves them into vertex position. Your doctor can try to move them again, but this gets harder as the baby gets bigger.

Breech birth problems. If you give birth in the breech position, your baby’s body may not be able to stretch your cervix enough for their head to come out. Your baby’s shoulders or head could get stuck against your pelvis.

Breech births can also cause your umbilical cord to go into your vagina before your baby does. This is an emergency and requires an immediate C-section.

C-section problems. Since this is a major surgery, infections, bleeding, and organ damage can happen. C-sections can also cause you to have issues with later pregnancies, such as a tear in your uterus or issues with your placenta.

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Breech, posterior, transverse lie: What position is my baby in?

Fetal presentation, or how your baby is situated in your womb at birth, is determined by the body part that's positioned to come out first, and it can affect the way you deliver. At the time of delivery, 97 percent of babies are head-down (cephalic presentation). But there are several other possibilities, including feet or bottom first (breech) as well as sideways (transverse lie) and diagonal (oblique lie).

Fetal presentation and position

During the last trimester of your pregnancy, your provider will check your baby's presentation by feeling your belly to locate the head, bottom, and back. If it's unclear, your provider may do an ultrasound or an internal exam to feel what part of the baby is in your pelvis.

Fetal position refers to whether the baby is facing your spine (anterior position) or facing your belly (posterior position). Fetal position can change often: Your baby may be face up at the beginning of labor and face down at delivery.

Here are the many possibilities for fetal presentation and position in the womb.

Medical illustrations by Jonathan Dimes

Head down, facing down (anterior position)

A baby who is head down and facing your spine is in the anterior position. This is the most common fetal presentation and the easiest position for a vaginal delivery.

This position is also known as "occiput anterior" because the back of your baby's skull (occipital bone) is in the front (anterior) of your pelvis.

Head down, facing up (posterior position)

In the posterior position , your baby is head down and facing your belly. You may also hear it called "sunny-side up" because babies who stay in this position are born facing up. But many babies who are facing up during labor rotate to the easier face down (anterior) position before birth.

Posterior position is formally known as "occiput posterior" because the back of your baby's skull (occipital bone) is in the back (posterior) of your pelvis.

Frank breech

In the frank breech presentation, both the baby's legs are extended so that the feet are up near the face. This is the most common type of breech presentation. Breech babies are difficult to deliver vaginally, so most arrive by c-section .

Some providers will attempt to turn your baby manually to the head down position by applying pressure to your belly. This is called an external cephalic version , and it has a 58 percent success rate for turning breech babies. For more information, see our article on breech birth .

Complete breech

A complete breech is when your baby is bottom down with hips and knees bent in a tuck or cross-legged position. If your baby is in a complete breech, you may feel kicking in your lower abdomen.

Incomplete breech

In an incomplete breech, one of the baby's knees is bent so that the foot is tucked next to the bottom with the other leg extended, positioning that foot closer to the face.

Single footling breech

In the single footling breech presentation, one of the baby's feet is pointed toward your cervix.

Double footling breech

In the double footling breech presentation, both of the baby's feet are pointed toward your cervix.

Transverse lie

In a transverse lie, the baby is lying horizontally in your uterus and may be facing up toward your head or down toward your feet. Babies settle this way less than 1 percent of the time, but it happens more commonly if you're carrying multiples or deliver before your due date.

If your baby stays in a transverse lie until the end of your pregnancy, it can be dangerous for delivery. Your provider will likely schedule a c-section or attempt an external cephalic version , which is highly successful for turning babies in this position.

Oblique lie

In rare cases, your baby may lie diagonally in your uterus, with his rump facing the side of your body at an angle.

Like the transverse lie, this position is more common earlier in pregnancy, and it's likely your provider will intervene if your baby is still in the oblique lie at the end of your third trimester.

Was this article helpful?

What to know if your baby is breech

What's a sunny-side up baby?

How your twins’ fetal positions affect labor and delivery

What happens to your baby right after birth

BabyCenter's editorial team is committed to providing the most helpful and trustworthy pregnancy and parenting information in the world. When creating and updating content, we rely on credible sources: respected health organizations, professional groups of doctors and other experts, and published studies in peer-reviewed journals. We believe you should always know the source of the information you're seeing. Learn more about our editorial and medical review policies .

Ahmad A et al. 2014. Association of fetal position at onset of labor and mode of delivery: A prospective cohort study. Ultrasound in obstetrics & gynecology 43(2):176-182. https://www.ncbi.nlm.nih.gov/pubmed/23929533 Opens a new window [Accessed September 2021]

Gray CJ and Shanahan MM. 2019. Breech presentation. StatPearls.  https://www.ncbi.nlm.nih.gov/books/NBK448063/ Opens a new window [Accessed September 2021]

Hankins GD. 1990. Transverse lie. American Journal of Perinatology 7(1):66-70.  https://www.ncbi.nlm.nih.gov/pubmed/2131781 Opens a new window [Accessed September 2021]

Medline Plus. 2020. Your baby in the birth canal. U.S. National Library of Medicine. https://medlineplus.gov/ency/article/002060.htm Opens a new window [Accessed September 2021]

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Malpresentation

8-minute read

If you feel your waters break and you have been told that your baby is not in a head-first position, seek medical help immediately .

• Malpresentation is when your baby is not facing head-first down the birth canal as birth approaches.
• The most common type of malpresentation is breech — when your baby’s bottom or feet are facing downwards.
• A procedure called external cephalic version can sometimes turn a breech baby into a head-first position at 36 weeks.
• Most babies with malpresentation are born by caesarean, but you may be able to have a vaginal birth if your baby is breech.
• There is a serious risk of cord prolapse if your waters break and your baby is not head-first.

What are 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, with the crown (top) of the baby’s head against the cervix, with the chin tucked 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 goes down the birth canal first, the risks to you and your baby may be higher. Malpresentation increases the chance that you will have a more complex vaginal birth or 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, with their face against the cervix.

Transverse lie

This is when your baby is lying sideways. Their back, shoulders, arms or legs may be the 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 an emergency if it leads to cord prolapse (when the cord is born before your baby, potentially reducing placental blood flow to your baby).

What is malposition?

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

If your baby is facing the front of your body (posterior position) or facing your side (transverse position) this is called malposition. Transverse position is not the same as transverse lie. A transverse position means your labour may take a bit longer and you might feel more pain in your back. Often your baby will move into a better position before or during labour.

Why might my baby be in the wrong position?

Malpresentation may be caused by:

• a low-lying placenta
• too much or too little amniotic fluid
• many previous pregnancies, making the muscles of the uterus less stable
• carrying twins or more

Often no cause is found.

Is it likely that my baby will be in the wrong position?

Many babies are in a breech position during pregnancy. They usually turn head-first as pregnancy progresses, and more than 9 in 10 babies in Australia have a vertex presentation (ideal presentation, head-first) at birth.

You are more likely to have a malpresentation if:

• this is your first baby
• you are over 40 years old
• you've had a previous breech baby
• you go into labour prematurely

How is malpresentation diagnosed?

Malpresentation is normally diagnosed when your doctor or midwife examines you, from 36 weeks of pregnancy. If it’s not clear, it can be confirmed with an ultrasound.

Can my baby’s position be changed?

If you are 36 weeks pregnant , it may be possible to gently turn your baby into a head-first position. This is done by an obstetrician using a technique called external cephalic version (ECV).

Some people try different postures or acupuncture to correct malpresentation, but there isn’t reliable evidence that either of these work.

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

Most babies with a malpresentation close to birth are born by caesarean . You may be able to have a vaginal birth with a breech baby, but you will need to go to a hospital that can offer you and your baby specialised care.

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.

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. These include how big your baby is, the position of your baby, the structure of your pelvis and whether you’ve had a caesarean in the past.

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

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

Vaginal breech birth

Risks to your baby can include:

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

Risks to you include:

• blood loss or blood clots
• infection in the wound
• problems with the anaesthetic
• damage to other organs nearby, such as your bladder
• a higher chance of problems 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

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, but it won’t necessarily happen in future pregnancies. If you’re worried, it may help to talk to your doctor or midwife so they can explain what happened.

Speak to a maternal child health nurse

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Last reviewed: July 2022

Related pages

Labour complications.

• Interventions during labour
• Giving birth - stages of labour

Breech pregnancy

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Top results

When a baby is positioned bottom-down late in pregnancy, this is called the breech position. Find out about 3 main types and safe birthing options.

Read more on Pregnancy, Birth & Baby website

Breech Presentation at the End of your Pregnancy

Breech presentation occurs when your baby is lying bottom first or feet first in the uterus (womb) rather than the usual head first position. In early pregnancy, a breech position is very common.

Read more on RANZCOG - Royal Australian and New Zealand College of Obstetricians and Gynaecologists website

Breech presentation and turning the baby

In preparation for a safe birth, your health team will need to turn your baby if it is in a bottom first ‘breech’ position.

Read more on WA Health website

External Cephalic Version for Breech Presentation - Pregnancy and the first five years

This information brochure provides information about an External Cephalic Version (ECV) for breech presentation

Read more on NSW Health website

Presentation and position of baby through pregnancy and at birth

Presentation and position refer to where your baby’s head and body is in relation to your birth canal. Learn why it’s important for labour and birth.

Even if you’re healthy and well prepared for childbirth, there’s always a chance of unexpected problems. Learn more about labour complications.

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Fetal Presentation, Position, and Lie (Including Breech Presentation)

• Key Points |

Abnormal fetal lie or presentation may occur due to fetal size, fetal anomalies, uterine structural abnormalities, multiple gestation, or other factors. Diagnosis is by examination or ultrasonography. Management is with physical maneuvers to reposition the fetus, operative vaginal delivery , or cesarean delivery .

Terms that describe the fetus in relation to the uterus, cervix, and maternal pelvis are

Fetal presentation: Fetal part that overlies the maternal pelvic inlet; vertex (cephalic), face, brow, breech, shoulder, funic (umbilical cord), or compound (more than one part, eg, shoulder and hand)

Fetal position: Relation of the presenting part to an anatomic axis; for transverse presentation, occiput anterior, occiput posterior, occiput transverse

Fetal lie: Relation of the fetus to the long axis of the uterus; longitudinal, oblique, or transverse

Normal fetal lie is longitudinal, normal presentation is vertex, and occiput anterior is the most common position.

Abnormal fetal lie, presentation, or position may occur with

Fetopelvic disproportion (fetus too large for the pelvic inlet)

Fetal congenital anomalies

Uterine structural abnormalities (eg, fibroids, synechiae)

Multiple gestation

Several common types of abnormal lie or presentation are discussed here.

Transverse lie

Fetal position is transverse, with the fetal long axis oblique or perpendicular rather than parallel to the maternal long axis. Transverse lie is often accompanied by shoulder presentation, which requires cesarean delivery.

Breech presentation

There are several types of breech presentation.

Frank breech: The fetal hips are flexed, and the knees extended (pike position).

Complete breech: The fetus seems to be sitting with hips and knees flexed.

Single or double footling presentation: One or both legs are completely extended and present before the buttocks.

Types of breech presentations

Breech presentation makes delivery difficult ,primarily because the presenting part is a poor dilating wedge. Having a poor dilating wedge can lead to incomplete cervical dilation, because the presenting part is narrower than the head that follows. The head, which is the part with the largest diameter, can then be trapped during delivery.

Additionally, the trapped fetal head can compress the umbilical cord if the fetal umbilicus is visible at the introitus, particularly in primiparas whose pelvic tissues have not been dilated by previous deliveries. Umbilical cord compression may cause fetal hypoxemia.

Predisposing factors for breech presentation include

Preterm labor

Uterine abnormalities

Fetal anomalies

If delivery is vaginal, breech presentation may increase risk of

Umbilical cord prolapse

Birth trauma

Perinatal death

Face or brow presentation

In face presentation, the head is hyperextended, and position is designated by the position of the chin (mentum). When the chin is posterior, the head is less likely to rotate and less likely to deliver vaginally, necessitating cesarean delivery.

Brow presentation usually converts spontaneously to vertex or face presentation.

Occiput posterior position

The most common abnormal position is occiput posterior.

The fetal neck is usually somewhat deflexed; thus, a larger diameter of the head must pass through the pelvis.

Progress may arrest in the second phase of labor. Operative vaginal delivery or cesarean delivery is often required.

Position and Presentation of the Fetus

If a fetus is in the occiput posterior position, operative vaginal delivery or cesarean delivery is often required.

In breech presentation, the presenting part is a poor dilating wedge, which can cause the head to be trapped during delivery, often compressing the umbilical cord.

For breech presentation, usually do cesarean delivery at 39 weeks or during labor, but external cephalic version is sometimes successful before labor, usually at 37 or 38 weeks.

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Why do babies prefer the vertex fetal presentation

What predisposes fetuses to orient themselves in the vertex presentation?

My doctor explained it with gravity but I am not convinced.

The head is the heaviest, fair enough. The gravitational pull experienced by a body is proportional to its mass. Hence the pull on the heavier head is greater.

While true, I don't see any explanatory value. Given it feels greater gravity on it's head, this just means the head feels heavier.

The fetus still orients through motor movements. What propels it to typically orient in the vertex presentation?

• I don't blame you for not believing the response you were given. It's simply wrong. @Timur Shtatland is correct. Simply put, the uterus can expand more (so is larger) at the top, where there are no bones, than the bottom, which is surrounded by ligaments and the bony pelvis. As the bottom half of a baby (buttocks and legs) is larger than the shoulders and arms, and the head smaller yet than those, the head-first presentation is pysiological, and most common. –  anongoodnurse Mar 24, 2021 at 16:19

Vertex presentation is caused by the shape of the uterus, rather than (directly) caused by gravity.

REFERENCES:

In vertex presentations the head of the fetus most commonly faces to the right and slightly to the rear. This position is said to be the most usual one because the fetus is thus best accommodated to the shape of the uterus.

Presentation | childbirth | Britannica: https://www.britannica.com/science/presentation#ref55860

The piriform (pear-shaped) morphology of the uterus has been given as the major cause for the finding that most singletons favor the cephalic presentation at term.

Cephalic presentation - Wikipedia: https://en.wikipedia.org/wiki/Cephalic_presentation

In about 95% of deliveries, the part of the fetus which arrives first at the mother’s pelvic brim is the highest part of the fetal head, which is called the vertex. This presentation is called the vertex presentation. Notice that the baby’s chin is tucked down towards its chest, so that the vertex is the leading part entering the mother’s pelvis. The baby’s head is said to be ‘well-flexed’ in this position. During early pregnancy, the baby is the other way up — with its bottom pointing down towards the mother’s cervix — which is called the breech presentation. This is because during its early development, the head of the fetus is bigger than its buttocks; so in the majority of cases, the head occupies the widest cavity, i.e. the fundus (rounded top) of the uterus. As the fetus grows larger, the buttocks become bigger than the head and the baby spontaneously reverses its position, so its buttocks occupy the fundus. In short, in early pregnancy, the majority of fetuses are in the breech presentation and later in pregnancy most of them make a spontaneous transition to the vertex presentation.

The Open University: Labour and Delivery Care Module: 8. Abnormal Presentations and Multiple Pregnancies: https://www.open.edu/openlearncreate/mod/oucontent/view.php?id=276&printable=1

• Thank you, this is lovely. –  superAnnoyingUser Mar 24, 2021 at 16:49

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Malpresentation and Malposition of the Fetus

A malpresentation or malposition of the fetus is when the fetus is in any abnormal position, other than vertex (head down) with the occiput anterior or posterior.

The following are considered malpresentations or malpositions:

Unstable lie

• Transverse presentation
• Oblique presentation

Face presentation

Brow presentation

Shoulder presentation

High head at term

• Prolapsed arm

The cause of a malpresentation can often not be clearly identified but it can be associated with the following:

• Preterm pregnancy
• Uterine anomalies
• Pelvic tumors eg f ibroids
• Placenta previa
• Grandmultiparty
• Contracted maternal pelvis
• Multiple gestation
• Too much amniotic fluyid (polyhydramnios)
• Short umbilical cord
• Fetal anomalies (e.g. anencephaly, hydro-cephalus)
• Abnormal fetal motor ability

There is an increased risk of neonatal and maternal complications associated with a malpresentation including neonatal and maternal trauma. If delivery is indicated, doing a cesarean delivery can significantly decrease the risk of complications.

Transverse lie

Oblique lie

In most cases of a normal vertex (head down) presentation, the baby's head is flexed with the chin close to the baby's chest. In these cases, the presenting part is the occiput, the posterior part of the baby's head. If the baby's head is more but not completekly extended then the baby's brow presents towards the vagina. A brow presentation is rare, maybe happening in about 1 in 2,000 births, more likely in pwomen with their second or subsequent births. A baby with a brow presentation can only deliver vaginally if the head flexes or extends.

Prolapsed arm 

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• v.2021(1); 2021

Eclampsia and posterior reversible encephalopathy syndrome (PRES): A retrospective review of risk factors and outcomes

Nissar shaikh.

1 Department of Anesthesia, SICU, Hamad Medical Corporation, Doha, Qatar

Shoaib Nawaz

2 Department of Anesthesia and Perioperative Medicine, Hamad Medical Corporation, Doha, Qatar E-mail: aq.damah@1zawans

Firdous Ummunisa

3 Department of Obstetrics and Gynecology, Women's Wellness and Research Center, Hamad Medical Corporation, Doha, Qatar

Aamir Shahzad

4 Department of Internal Medicine, Hamad Medical Corporation, Doha, Qatar

Jazib Hussain

Kiran ahmad.

5 Department of Communicable Diseases, Hamad Medical Corporation, Doha, Qatar

Haleema S Almohannadi

Hussein attia sharara.

6 Department of Obstetrics and Gynecology, AlKhor Hospital, Hamad Medical Corporation, Qatar

Posterior reversible encephalopathy syndrome (PRES) is a clinical and radiological entity initially described in 1996. PRES frequently develops in patients with preeclampsia and eclampsia. There is not much literature on risk factors causing PRES in pregnant patients with eclampsia. This study aimed to determine the incidence of PRES in eclampsia, its association with pregnancy, risk factors, and maternal and perinatal outcomes.

Patients and methods: All patients who were admitted with eclampsia and developed PRES in an intensive care unit of a tertiary medical facility between 1997 and 2017 were included in the study. Patients’ demographics, pregnancy and gestational data, treatment mode, and outcomes were retrospectively obtained from their medical charts/files. Data were entered using SPSS program version 23. Chi-square test was used to compare the variables, and a p value of < 0.05 was considered statistically significant.

Results: A total of 151 patients were admitted during the study period, and 25 developed PRES. The diagnosis was common in patients older than 25 years. Eclampsia patients who developed PRES were without any pregnancy-associated comorbidities ( p  < 0.08). At the time of diagnosis, their gestational age was more than 36 weeks, which was significant ( p  < 0.04). Incidence was significantly higher in patients presenting with eclampsia and had recurrent seizures ( p  < 0.01 and 0.002, respectively). Its incidence was significantly higher in postpartum eclampsia patients ( p  < 0.01). It was also significantly higher in patients who had cesarean section and hypertension treated with labetalol ( p  < 0.001 and 0.02, respectively). Overall, the maternal mortality rate of eclampsia patients complicated with PRES was 4% in our population.

Conclusion: Of eclampsia patients, 16% developed PRES, which is on the lower side than the reviewed literature (10%–90%). Eclampsia on presentation, recurrent seizures, postpartum eclampsia, cesarean delivery, and labetalol use were associated with increased risk of PRES development.

Introduction

Posterior reversible encephalopathy syndrome (PRES) commonly manifests as a confusional state, convulsion, or acute blindness. 1 , 2

Magnetic resonance imaging (MRI) usually shows typical bilateral white matter changes. Usually, these clinical and radiological changes are reversible in two to three weeks. 1 , 3 PRES is commonly caused by severe hypertension, eclampsia, preeclampsia, sepsis, renal failure, and immunosuppressive therapy. 3 , 4 Eclampsia is an important and frequent etiology of PRES. 5 , 6 There is a scarcity of literature about pregnancy- and eclampsia-related risk factors for developing PRES in eclampsia patients. 3 , 4 , 7 Brewer et al., 4 found that 46 of 47 eclampsia patients had PRES syndrome; however, they did not find any significant differences in the incidence between ethnicity groups, maternal age, or gestational age.

This study aimed to determine the incidence of PRES in eclampsia, its association with pregnancy, risk factors, and maternal and perinatal outcomes.

Patients And Methods

After obtaining permission for the eclampsia study from the department and the institutional review board (IRB Research proposal Number: 10044/10), all eclampsia patients diagnosed with PRES, from 1997 to 2017, were included in the study. The data were gathered as a chart review, which was conducted retrospectively. All patients who were admitted to the hospital with the diagnosis of eclampsia within the study period were included in the review. The project research team, consisting of five members, reviewed all charts with eclampsia as their primary diagnosis. These charts were randomly selected from all eclampsia patients admitted to the hospital. Of 151 patients who developed eclampsia, only 25 were diagnosed with PRES, and these patients were used in the statistical analysis. These patients were included in the study according to the definitions of the diseases in the Definitions section. All patients were managed in an intensive care unit (ICU) and underwent MRI for the diagnosis of PRES. Computed tomography (CT) scan was also performed for these patients, and an abnormal CT scan included brain infarction in the posterior, parietal, and occipital areas. Patient's demographic data, comorbidities, gestational weeks, parity, fetal delivery mode, imaging studies, antihypertensive and anticonvulsant medications, and maternal and perinatal outcomes were recorded retrospectively.

Inclusion criteria

All pregnant patients who were diagnosed with eclampsia and developed PRES were included in the study.

Exclusion criteria

Patients who had a diagnosis of PRES due to any other primary conditions such as sepsis, hypertension, and immunosuppression therapy were excluded from the study.

Definitions

PRES in eclampsia patients is diagnosed with clinical features of altered mental status, headache, and/or visual disturbances along with MRI, findings of bilateral symmetrical hyperintensities on tbl2-weighted images in the parietal and occipital lobes, and no other alternative differential diagnosis consistent with PRES. 8

Glasgow Coma Scale (GCS) is a neurological scale that aims to provide a reliable and objective way of recording a person's state of consciousness for initial and subsequent assessment. It is used to assess PRES as most patients who develop this syndrome present with a drop in their GCS scores.

Number of fits were categorized into only single episode (1), two episodes, or more than two (multiple) episodes of seizures.

Antenatal visits were divided into two as follows: less than 10 visits were categorized as not regularly followed and 10 or more visits as regular antenatal care. This was taken from the guidelines of the World Health Organization regarding antenatal visits.

Hypertensive disorders of pregnancy

These include all of the following mentioned entities: preeclampsia, all eclampsia types, hemolysis, elevated liver enzymes, and low platelets (HELLP) syndrome, and gestational hypertension. Further definitions are given as follows:

Preeclampsia refers to the new onset of hypertension and proteinuria or the new onset of hypertension and significant end-organ dysfunction with or without proteinuria after 20 weeks’ gestation in a previously normotensive woman. Hypertension is defined in pregnancy as systolic blood pressure ≥ 140 mmHg and/or diastolic blood pressure ≥ 90 mmHg.

Eclampsia refers to the occurrence of a grand mal seizure in a woman with preeclampsia in the absence of other neurological conditions that could account for seizure.

Antepartum eclampsia is defined as having eclampsia from 20 weeks’ gestation to labor onset. Intrapartum eclampsia is defined as the occurrence of seizures during normal delivery or lower segment cesarean section. Postpartum eclampsia is defined as the occurrence of seizures within 10 days of delivery.

HELPP syndrome is a complication of late pregnancy characterized by hemolysis, elevated liver enzymes, and low platelets.

Chronic hypertension in pregnancy is diagnosed before 20 weeks’ gestation and gestational hypertension after 20 weeks’ gestation.

All these definitions are important to understand since the primary diagnosis of eclampsia and PRES is based on these definitions. All patients who were positively diagnosed with PRES and eclampsia according to the above definitions were included in this study.

Statistical analysis

Data were entered and analyzed using IBM SPSS version 23. Descriptive statistics in the form of mean and standard deviation were performed for interval variables. Frequency with percentages was calculated for categorical variables. Chi-square tests were performed to determine the association between categorical variables. Student t -tests (unpaired) were performed to determine statistically significant mean differences between interval variables. The interval variables were detected as normal using the Kolmogorov–Smirnov tests. Multivariate analysis could not be performed because of inappropriate sample size. A p value of ≤ 0.05 (two tailed) was considered statistically significant.

The total number of deliveries during the study period was 463,016, from which 151 patients had eclampsia and 25 PRES. The average GCS score was 14 ± 1. Of patients, 60% were more than 25 years old ( Figure 1 ).

The percentage of maternal and fetal mortality in posterior reversible encephalopathy syndrome.

PRES eclampsia was less common in the local population (40% vs. 60%), and it was significantly higher ( p  < 0.008) in patients with no pregnancy-associated comorbidity. PRES was more common in multiparous patients (52% vs. 48%). The incidence was significantly higher ( p  < 0.04) after 36 weeks’ gestation. It was significantly higher despite regular antenatal care ( p  < 0.002). The incidence was significantly higher in patients with eclampsia than in those with preeclampsia ( p  < 0.01). The common mode of fetal delivery was lower segment cesarean section, and these patients had a significantly higher incidence of PRES ( p  < 0.001). PRES was significantly higher in postpartum eclampsia patients ( p  < 0.01) than in prepartum and intrapartum eclampsia patients. The incidence was significantly higher ( p  < 0.02) in patients with recurrent seizures ( Table 1 ). Of patients, 20% received magnesium sulfate (MgSO 4 ), 44% benzodiazepines in addition to MgSO 4 , 16% MgSO 4 and an anticonvulsant, and 20% MgSO 4 , benzodiazepines, and anticonvulsants to control seizures ( Table 1 ). PRES was significantly higher when labetalol was used to control hypertension in eclampsia patients ( p  < 0.02; Table1). CT brain scans of PRES eclampsia patients were normal in 44% and showed infarction in the posterior, parietal, or occipital areas in 56%. In all patients, MRI was diagnostic of PRES ( Table 1 ). Most PRES patients were discharged with antihypertensive and anticonvulsant medications ( Table 1 ). The average length of ICU stay of PRES eclampsia patients was 4 ± 2 days. The maternal mortality rate was 4% as 1 of 25 patients died with HELLP syndrome and severe thrombocytopenia complications. The perinatal mortality rate was 16% (4 of 25 fetal deaths; Figure 2 ). These rates were calculated considering our sample size of 25 patients with diagnosis of PRES.

Posterior reversible encephalopathy syndrome and patients’ age.

Posterior reversible encephalopathy syndrome (PRES) and variables.

PRES is a potentially reversible neurological entity, presenting with altered consciousness, acute cortical blindness, and convulsions. Delayed diagnosis can lead to poor prognostic indicators. 9 Typical imaging study findings include vasogenic edema with or without ischemic changes in the posterior brain circulation. 10

There is limited knowledge regarding the development of PRES in eclampsia patients and its associated risk factors from our region. 4 , 5 , 11 – 13

Eclampsia is a common etiological reason for developing PRES. 6 It is well described in the literature that these patients with hypertensive disorders of pregnancy are at a higher risk of developing PRES as they have episodes of hypertension and etiopathology of vascular nature, in conjunction with disturbed blood brain barrier and vasogenic brain edema. 4 – 6 This study aimed to assess pregnancy-related risk factors and their association with the development of PRES. This study aimed to determine the associated risk factors, address them in the antenatal period, and improve outcomes by preventing PRES in these high-risk groups.

The rate of eclampsia patients who developed PRES was lower in this study (16%) than in Wen et al.’s 14 study (92.85%). 4 In contrast, Bembalgi et al., 15 reported a significantly lesser incidence of PRES in eclampsia patients (0.03%), although they did not mention whether these patients were managed in an intensive care setup or ward. The maternal age of eclampsia patients developing PRES in this study was significantly higher than in the literature. Bembalgi et al., 12 had younger eclampsia patients developing PRES (20–25 years old). Fisher et al., 15 also described younger maternal age as a risk for developing PRES in eclampsia patients. Although various risk factors for developing PRES in eclampsia patients are described in this study, 56% of PRES eclampsia patients had no comorbidities and pregnancy-associated risk factors, 28% had preeclampsia, and 16% had gestational diabetes mellitus. Roth et al., 16 also compared PRES patients with and without pregnancy and reported that 75% of the pregnant patients were without any comorbidity, one patient had hypertension, and one had obesity, whereas 23% of nonpregnant patients developing PRES had diabetes mellitus. Most of the PRES eclampsia patients in this study were multiparous. In the literature, PRES is described to be common in primiparous patients. 12 , 17 Postpartum eclampsia patients had a significantly higher incidence of PRES in this study than in Mavani et al.’s 17 study, although Bembalgi et al., 15 also reported a higher incidence.

Most patients had single or recurrent episodes of seizure activity in contrast to what was described in the literature. 4 , 12 , 17 It may be related to the use of MgSO 4 in this study as it reduces the occurrence of recurrent seizures. The eclampsia patients who developed PRES in this study had a significantly higher recurrent seizure activity. The common mode of fetal delivery was lower segment cesarean section, which was also described in the literature. 15 The gold standard for the diagnosis of PRES is MRI; in this study, 44% of the PRES patients had normal CT brain, but all had PRES confirmation by MRI. 18 Initially, CT scan was performed in these patients to rule out gross central nervous system (CNS) pathology such as hemorrhage or infarction. Subsequently, these patients underwent MRI for final diagnosis.

In this study, eclampsia patients treated with labetalol infusion to control blood pressure had a significantly higher rate of PRES, and this may be related to the effects of β-blockers on the CNS. A prospective randomized study will be needed to confirm this finding.

PRES in general has a good outcome. One PRES eclampsia mother died in this study; she had HELLP syndrome apart from PRES and eclampsia with severe thrombocytopenia. Wen et al., 14 also reported a maternal mortality of 7.69%, and both patients had disseminated intravascular coagulopathy. Bambalgi et al., 12 had a better maternal outcome for PRES eclampsia patients but had a higher perinatal mortality (27.3%), whereas Fugate et al., 19 reported a mortality rate of up to 6%. In our study, the perinatal mortality was 16%.

Limitations

Limitations of this study include that it is a single-center retrospective study and has a comparatively small sample size. Further prospective multicenter studies are required for better quality data and recommendation.

Binary regression analysis to assess the risk factors associated with the diagnosis could not be conducted because of the small sample size.

PRES incidence did not decrease despite regular antenatal care in our patients. Another prospective large multicenter study is needed to determine the possible reasons.

Conclusions

In this study, eclampsia patients who developed PRES had higher gestational age and recurrent seizure episodes. They also had a higher number of cesarean deliveries, postpartum eclampsia, and labetalol use to control blood pressure. The absence of pregnancy-associated comorbidities did not decrease the incidence of PRES in eclampsia patients.

In the end, a low threshold is recommended for the possibility of diagnosing PRES in eclampsia patients who develop neurological symptoms, particularly in patients having the abovementioned risk factors. This neurological disorder is potentially reversible with early diagnosis and appropriate management.

Acknowledgements

The abstract of this study was presented in the 1st Qatar Critical Care Conference in 2019.

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Diagnosis of vte in pregnant patients, case 1 (continued), case 2 (continued), treatment of vte in pregnant patients, management of delivery in women with vte, postpartum duration of anticoagulant treatment, prevention of recurrent vte in a subsequent pregnancy, acknowledgment, how i treat venous thromboembolism in pregnancy.

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Saskia Middeldorp , Wessel Ganzevoort; How I treat venous thromboembolism in pregnancy. Blood 2020; 136 (19): 2133–2142. doi: https://doi.org/10.1182/blood.2019000963

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Visual Abstract

One to 2 pregnant women in 1000 will experience venous thromboembolism (VTE) during pregnancy or postpartum. Pulmonary embolism (PE) is a leading cause of maternal mortality, and deep vein thrombosis leads to maternal morbidity, with postthrombotic syndrome potentially diminishing quality of life for a woman’s lifetime. However, the evidence base for pregnancy-related VTE management remains weak. Evidence-based guideline recommendations are often extrapolated from nonpregnant women and thus weak or conditional, resulting in wide variation of practice. In women with suspected PE, the pregnancy-adapted YEARS algorithm is safe and efficient, rendering computed tomographic pulmonary angiography to rule out PE unnecessary in 39%. Low molecular weight heparin (LMWH) in therapeutic doses is the treatment of choice during pregnancy, and anticoagulation (LMWH or vitamin K antagonists [VKAs]) should be continued until 6 weeks after delivery, with a 3-month minimum total duration. LMWH or VKA use does not preclude breastfeeding. Postpartum, direct oral anticoagulants are an option if a woman does not breastfeed and long-term use is intended. Management of delivery, including type of analgesia, requires a multidisciplinary approach and depends on local preferences and patient-specific conditions. Several options are possible, including waiting for spontaneous delivery with temporary LMWH interruption. Prophylaxis for recurrent VTE prevention in subsequent pregnancies is indicated in most women with a history of VTE.

Women who experience venous thromboembolism (VTE) during pregnancy or the postpartum period face a potentially life-threatening condition. 1,2   VTE occurs in 1 to 2 of 1000 pregnancies, and the risk increases with age, mode of delivery, and presence of comorbid conditions. 3-5   Almost half of women with deep vein thrombosis (DVT) in pregnancy experience a reduced quality of life as a result of postthrombotic syndrome, because thrombosis in pregnant and postpartum women predominantly affects the iliac or iliofemoral veins. 6   Approximately two-thirds of lower-extremity DVTs occur antepartum, with an approximately equal distribution over the trimesters. 7,8   The epidemiology of pulmonary embolism (PE) seems to differ slightly from that of DVT, with a majority of pregnancy-related episodes of PE occurring in the postpartum period. 3   Given the much longer duration of the antepartum period vs the postpartum period, the daily absolute risk of VTE is highest postpartum.

A challenge in dealing with VTE issues in pregnant and postpartum women is the absence of high-quality evidence in this distinct population, although some progress has been made since the 2011 "How I treat" article 9   on this topic from one of the current authors (S.M.). In the absence of evidence, it is impossible to identify optimal management, and there is wide variation among physicians, centers, and countries. In this review, we will discuss how we treat pregnancy-related VTE based on 2 patient histories from our clinical practice in an academic hospital in The Netherlands.

A 32-year-old woman 11 weeks into her pregnancy presented to the emergency department in a teaching hospital with a 3-day history of left-sided chest pain that increased with inspiration, along with a 1-day history of shortness of breath. She had no other symptoms, most notably no fever, hemoptysis, or complaints about her legs. In the past month, she had been admitted to hospital twice because of hyperemesis and had also made a return trip to the United States (ie, 2 8-hour flights) 2 weeks before presentation. She had not received thrombosis prophylaxis. Her medical history was uneventful, except for an early miscarriage 3 years earlier; her family history was negative for VTE. On physical examination, her body weight was 78 kg with a BMI of 23.8 kg/m 2 . She appeared somewhat short of breath and in pain, with a respiratory rate of 22 excursions per minute, temperature of 38.2°C, blood pressure of 115/70 mmHg, regular pulse of 95 beats per minute, transcutaneous oxygen saturation of 95% on room air, and no abnormalities on chest examination. Her legs did not show signs of DVT. Laboratory results showed a normal hemoglobin level (12.6 g/dL), mild leukocytosis (11.4 × 10 9 /L), and a D-dimer level of 10 080 ng/mL. Chest radiograph was normal. Bilateral compression ultrasonography (CUS) of the legs showed normal compressibility of the femoral and popliteal veins and no signs of flow obstruction of the iliac veins on either side. Next, computed tomography pulmonary angiography (CTPA) was performed, which showed multiple central bilateral pulmonary emboli with a normal right/left ventricle ratio (ie, no signs of right ventricular dysfunction) and a small infarction in the left lung.

A 27-year-old woman 32 weeks into her pregnancy was transported to our emergency department because of a unilateral car accident; she had hit the guardrail of the highway. At presentation, she was unconscious, with pupils reactive on both sides, no pareses, and multiple facial injuries. Her blood pressure was 128/77 mmHg and pulse 115 beats per minute; she had a pregnant womb according to gestational age, with fetal movements observed by physical examination. Additional trauma screening revealed multiple cerebral contusional foci, intraparenchymal and subarachnoid hemorrhages, and fractures of the skull base and mastoid and sphenoid bones with pneumencephaly. Obstetric ultrasound revealed a vital fetus, without signs of placental hematoma or abruption. The present pregnancy had been uneventful except for some edema to just above the ankle on the right side for ∼2 months, without swelling of her upper leg. Two weeks before the accident, whole-leg CUS including visualization of the iliac vein had been normal. Because of the possibility that she had lost consciousness before the accident, PE was considered. On bilateral compression ultrasound, she was found to have DVT of her left femoral vein and no signs of iliac vein obstruction; on the right side, no abnormalities were seen. CT scan of the abdomen confirmed the absence of iliac vein involvement, and CTPA confirmed the diagnosis of bilateral PE, with clear signs of right ventricular dysfunction, a right/left ventricle ratio of >1, and flattening of the septum.

In pregnancy, specific aspects in the diagnosis of DVT and PE need to be considered. The threshold of suspicion in pregnancy is low, because VTE is a major cause of maternal morbidity and mortality. As a consequence of this, combined with the frequency of dyspnea and chest discomfort even in healthy pregnancies, the number needed to test to find a confirmed diagnosis is markedly higher than that in the nonpregnant population. Few studies have addressed the utility of an empirical clinical probability assessment or pregnancy-specific clinical decision rule, with or without the use of D-dimer levels. 10,11   D-dimer levels increase during pregnancy and are often higher than the regular threshold of 500 ng/mL, thus triggering further imaging for VTE diagnosis. 12   Imaging of the lungs for PE exposes both the pregnant woman and her fetus to radiation. Radiation exposure of the fetus is lowest for CTPA, whereas exposure of the proliferating breast tissue of the woman may be lower with ventilation/perfusion (V/Q) scanning. 13-15   This is the reason why V/Q scanning is still the first test ordered in many North American centers, as is suggested in the American Society of Hematology (ASH) 2018 guideline. 15   This guideline clearly points out that both techniques have their own risks and benefits. 15   However, V/Q scanning is not widely available, and it is likely that pregnancy-adapted CTPA techniques are able to reduce the amount of maternal radiation without compromising sensitivity.

In 2018 and 2019, 2 well-sized multicenter prospective outcome studies in pregnant women with suspected PE were published, providing an evidence-based approach to this diagnostic challenge. 16-18   In the first study, 395 women with suspected PE from 11 centers in France and Switzerland were included. 16   PE was excluded in women with low or intermediate pretest clinical probability based on the revised Geneva score and a D-dimer level <500 ng/mL. Women with high pretest clinical probability or a D-dimer of ≥500 ng/mL underwent bilateral CUS of the legs, followed by CTPA (or V/Q scan in the case of nondiagnostic CTPA) if no DVT was found. The prevalence of VTE was 7.1%; one-quarter of these diagnoses were proximal DVTs found on ultrasound, whereas the remainder were positive CTPA results. The strategy proved to be safe, with a rate of symptomatic VTE at 3-month follow-up of 0.0% (95% confidence interval [CI], 0.0% to 1.0%) among untreated women. CTPA could be avoided in 12% based on a D-dimer of <500 ng/mL combined with low or intermediate clinical probability.

In the second study, 498 pregnant women from 18 centers in France, Ireland, and The Netherlands were managed with the pregnancy-adapted YEARS algorithm ( Figure 1 ). 17   PE was excluded in women with a D-dimer <500 ng/mL and ≥1 YEARS item (clinical signs of DVT, hemoptysis, and PE as the most likely diagnosis) or <1000 ng/mL and no YEARS items. Adaptation of the YEARS algorithm for pregnant women involved CUS, but only for women with symptoms of DVT; if the results were positive, CTPA was not performed. The prevalence of VTE was 4%; one-fifth of these diagnoses were proximal DVTs found on ultrasound, whereas the others were positive CTPA results. The strategy proved to be safe, with a rate of symptomatic VTE of 0.21% (95% CI, 0.04% to 1.20%). The upper limit of the 95% CI meets the 1.82% cutoff proposed by the International Society on Thrombosis and Haemostasis (ISTH) for confirming the safety of VTE diagnostic strategies. 19   CTPA could be avoided in 39% of pregnant women. The proportions of women who were managed without CTPA were 65% in the first trimester, 46% in the second trimester, and 32% in the third trimester. On this basis, we consider the pregnancy-adapted YEARS algorithm safe and efficient, and it is the diagnostic strategy we practice in our hospital in women with suspected PE during pregnancy. Of note, in both management studies, the proportion of protocol deviations was high, indicating the challenge of using these strategies in this population. In our case 1, which occurred before publication of these management studies, the patient underwent a bilateral CUS despite the absence of leg symptoms.

Pregnancy-adapted YEARS algorithm for diagnosis of PE in pregnant women. 17,18  

The patient in our case 2 had had atypical leg symptoms 2 weeks before the diagnosis of PE. At that time, a formal pregnancy-adapted clinical probability assessment was not performed, but the likelihood based on clinical judgment was considered low, and DVT was considered ruled out after a negative whole-leg compression ultrasound with visualization of the iliac vein. For DVT, a pregnancy-adapted clinical prediction rule has been developed and has been retrospectively validated. In our patient, the LEFt rule (ie, symptoms in the left leg [L], calf circumference difference ≥2 cm [E for edema], and first trimester presentation [Ft]) would have been 0, indicating low clinical probability. 10,20   Prospective validation of a sequential diagnostic strategy based on the assessment of clinical probability with the LEFt rule, D-dimer measurement, and complete CUS in pregnant women with suspected DVT is ongoing (registered at www.clinicaltrials.gov as #NCT01708239). The ASH 2018 guideline suggests performing serial ultrasound in women with an initial negative ultrasound, but in a prospective cohort study of 221 pregnant women assessing this strategy, all 16 DVTs were diagnosed on the first ultrasound. 15,21   In another prospective study using a single whole-leg compression ultrasound to exclude DVT, the incidence of VTE during 3-month follow-up was low (1.1%; 95% CI, 0.3% to 4.0%), although the upper limit of the 95% CI does not exclude a potentially unacceptable failure rate. 22   At present, we do not recommend using the LEFt rule; instead, we use a single whole-leg ultrasound with visualization of the iliac vein in women with suspected DVT.

It is important to stress that in the case of leg symptoms that suggest a pelvic vein thrombosis (mainly a swollen upper leg or pain in the buttock), and if there is uncertainty about the adequacy of ultrasonographic visualization of the iliac vein, magnetic resonance imaging may be considered as an additional test, although this technique is not validated for DVT. We will never be able to tell for sure whether our case 2 patient had DVT in her right leg that was not diagnosed, although we still deem that unlikely.

Our patient was treated with low molecular weight heparin (LMWH; 14 000 IU of tinzaparin once daily, based on body weight at the time of diagnosis) and admitted to the obstetric ward for 5 days for pain relief with tramadol and acetaminophen. After hospital discharge, she continued with the same dose of LMWH, to which she adhered and tolerated well apart from some mild bruising around the injection sites. She had adequate peak anti-Xa levels throughout pregnancy and normal platelet counts. Her chest pain subsided after a few weeks, but she remained somewhat short of breath throughout pregnancy. At a gestational age of 30 weeks, we performed CTPA, because she felt increasingly breathless and was tachycardic, without another clear explanation such as anemia. CTPA showed complete resolution of PE and lung infarction.

Our patient had probably collapsed, which led to her car accident, as a result of massive central PE with signs of right ventricular dysfunction. At presentation, she was tachycardic, but her blood pressure was adequate. Clearly, she had an absolute contraindication for both thrombolysis and therapeutic dose anticoagulation because of the neurotrauma. In the hours after admission, her cardiorespiratory status deteriorated, and after careful multidisciplinary consideration, it was decided to perform a combined procedure under general anesthesia. The interventional radiologist placed an inferior vena cava (IVC) filter through the right femoral vein below the renal veins, and the obstetrician delivered the baby through a cesarean section. After delivery, the radiologist performed thrombosuction of the pulmonary arteries with a single bolus infusion of 5000 IU of unfractionated heparin (UFH). She was then treated with a prophylactic dose of LMWH (2850 IE of nadroparin) for 6 weeks, until the intracerebral blood was fully resorbed. Unfortunately, attempts to retrieve the filter were not successful.

LMWH is the drug of choice in pregnant women, because it does not cross the placenta or have teratogenic effects. 15   Table 1 lists the safety of several anticoagulants during pregnancy or breastfeeding.

Summary of safety of anticoagulant use in pregnancy and during breastfeeding

Data adapted. 15  

DOAC, direct oral anticoagulant; VKA, vitamin K antagonist.

Optimal use of therapeutic doses of LMWH in pregnant women is generally extrapolated from the nonpregnant population. For the initial treatment of acute VTE in pregnancy, there is no evidence base supporting a twice-daily regimen over a once-daily regimen of a therapeutic dose of LMWH. 15   It is unclear whether the prepregnancy weight or the actual body weight should be used to determine the appropriate dose of LMWH, and we use the actual body weight at time of diagnosis. Although there is no evidence that anti-Xa level monitoring and subsequent dose adjustments improve clinical outcomes, there is no evidence to demonstrate these are harmful either. 15   In our institution, we have the test available, and in women with acute VTE, we monitor anti- Xa levels 4 hours after injection and target to an anti-Xa level of 0.8 to 1.6 with a once-daily regimen at 6- to 8-week intervals. Practical advice is to instruct women to inject themselves in the morning, thus meeting the 4-hour postinjection time point of blood withdrawal.

The maternal safety issue of any anticoagulant is the risk of bleeding. The risk of anticoagulant-associated bleeding is thought to be low, 23   because most bleeding in pregnant woman has a primary obstetric origin. A systematic review and meta-analysis that included 18 observational studies describing 981 pregnant patients using therapeutic-dose anticoagulation treatment (LMWH or UFH) for treatment of acute VTE reported an antepartum incidence of hemorrhagic complications of 3.28% (95% CI, 2.10% to 4.72%). 24  

LMWH leads to local bruising and skin reactions in up to 25% of pregnant patients, which are mainly type IV delayed hypersensitivity reactions at the injection site of subcutaneously administered LMWH. 25,26   Type I allergy is rare and should always be considered, but if no symptoms or signs are present, we pragmatically switch to another LMWH. 25,27   If all registered LMWHs lead to skin problems, danaparoid sodium or fondaparinux can be considered. A rare but serious maternal complication of heparin is heparin-induced thrombocytopenia (HIT). The incidence of HIT in pregnant patients is very low (<0.1%), but some case reports have been published. 28   Although the ASH 2018 guideline on HIT suggests against platelet monitoring in patients at very low risk, 29   this is a conditional recommendation, and in our institution, we monitor platelets at baseline and between 4 and 12 days postinitiation of therapy, at a time that is most practical for the patient if she is treated outside the hospital, and at infrequent intervals (6-8 weeks, coinciding with anti-Xa level and obstetric follow-up visits) thereafter. Although long-term UFH use has been associated with symptomatic osteoporosis in up to 2% of patients, 30   contemporary studies of LMWH have shown that this is not an issue. 31  

Other anticoagulants and their use in pregnancy are either less preferred or contraindicated ( Table 1 ). UFH can be administered both IV and subcutaneously and has a similar safety profile with regard to fetal safety but requires activated partial thromboplastin time monitoring and is associated with a higher risk of HIT. 32   It is often considered for women in whom rapid reversal of the anticoagulant effect may be needed. However, these presumed benefits are offset by difficulty in maintaining therapeutic activated partial thromboplastin time results, with the obvious risk of extending thrombosis as a result of undertreatment in a woman with acute VTE and overanticoagulation in a woman in whom this option is chosen because of an increased risk of bleeding. 33   In such patients, we choose a twice-daily LMWH regimen based on actual body weight over IV unfractionated heparin, with the theoretical rationale that peak anti-Xa levels are somewhat lower (at a similar area under the curve) than with a once-daily regimen 34   and that in case of a bleeding emergency LMWH can still be partially neutralized by protamine sulfate.

Danaparoid also does not cross the placenta and can be used if LMWH is not an option, (eg, in the rare case of HIT). 35   Fondaparinux crosses the placenta to some extent, and experience in human pregnancies, particularly during the first trimester, is limited. 15,36,37   Nevertheless, we have used fondaparinux in a few women who were suspected of having type I allergy to LMWH during pregnancy. LMWH, danaparoid, and fondaparinux can be safely used in women who breastfeed. 15  

Because VKAs cross the placenta and may cause coumadin embryopathy and long-term effects, we avoid the use of these agents throughout the entire pregnancy for the treatment and prevention of VTE. 15,38,39   VKAs can be used during breastfeeding. 15  

DOACs (eg, direct thrombin inhibitors and factor Xa inhibitors) are contraindicated in pregnancy and during breastfeeding. 15   There is limited human safety evidence in the literature, and there seems to be animal toxicity according to the manufacturer’s summary of product characteristics. 40,41   If a woman inadvertently becomes pregnant while using a DOAC, we advise switching to LMWH immediately. 42   DOAC use is not regarded as medical grounds for the termination of a pregnancy. 43   Physicians are recommended to report all DOAC exposure during pregnancy to the ISTH registry. 44  

Systemic thrombolysis should be considered in pregnant patients with PE who are hemodynamically unstable, because this condition is associated with high maternal and fetal mortality. In a literature review, 23 cases involving the use of systemic thrombolysis in pregnancy for massive PE were identified. 45   There were no maternal deaths, and bleeding complications were reported in 39% of the cases. Bleeding was classified as major in 22% of women, 9% of the fetuses died, and 39% of pregnancies resulted in preterm delivery. Of course, the findings may not be accurate as a consequence of publication bias. However, the key message is that thrombolysis should not be withheld in pregnant women with life-threatening hemodynamic instability and PE, in whom risk to the fetus and risk of severe bleeding in the mother must be accepted in view of her life-threatening condition. 15   Whether catheter-directed thrombolysis for severe PE is associated with a lower risk of bleeding than systematic thrombolysis is unknown, even in the nonpregnant population. 46   Therefore, in our case 2 patient, we chose to perform catheter-directed thrombosuction without addition of thrombolytic agents. We generally avoid placement of an IVC filter in pregnant patients, because experience during pregnancy is limited, and filter migration and inferior caval vein perforation have been described. 47   This may be disregarded in exceptional circumstances, as in our case 2 patient, in whom it was anticipated that the absolute contraindication for therapeutic anticoagulation would persist for weeks.

Our patient went into spontaneous labor at a gestational age of 39 + 2 weeks and delivered a healthy daughter 21 hours after the last injection of LMWH. Estimated blood loss was 200 mL, and LMWH was restarted 12 hours after delivery at full dose.

Several options for delivery in women using anticoagulants are possible and depend strongly on local preferences and experience, which result from the perception of risks and benefits of either the wait-for-spontaneous-delivery approach or the planned-delivery approach. The ASH 2018 guideline panel suggests cessation of LMWH with spontaneous onset of labor in pregnant women receiving prophylactic-dose LMWH and planned delivery with prior discontinuation of anticoagulant therapy in pregnant women receiving therapeutic-dose LMWH. 15   Of note, this conditional recommendation is based on very low certainty in evidence about effects and hence raised substantial discussion among the panel members; the pros and cons are discussed in detail in the guideline. One panelist who advocated allowing spontaneous labor with therapeutic-dose LMWH “even with the potential for limiting access to neuraxial analgesia and anesthesia and potentially increasing the risk of major bleeding” 15 (p3331) was one of the current authors (S.M.). In our institution, this wait-for-spontaneous-delivery approach is the default choice with all dosages. We pragmatically base this on the fact that advantages and disadvantages of both approaches are limited, and we primarily follow the golden rule of in dubio abstine (ie, when in doubt, abstain). The potential disadvantages of unplanned spontaneous delivery are the increased risk of bleeding and limiting accessibility to neuraxial analgesia. With regard to the potential increase in major postpartum bleeding, data are very conflicting and of low quality. 43   In a systematic review, rates of bleeding in the postpartum period could be retrieved for 13 studies including 725 pregnancies. 24   Bleeding events occurred in 38.8% of patients; major bleeding (≥1000 mL) occurred in 1.9% (95% CI, 0.80% to 3.60%), and clinically relevant nonmajor bleeding (≥500 to 1000 mL) occurred in 5.7%; the remainder were minor bleeds (<500 mL). In our own retrospective cohort study of 95 women receiving therapeutic-dose LMWH, the incidence of postpartum hemorrhage, defined as >500 mL of blood loss, was 18%, which was similar to the rate of 22% in 524 women not using anticoagulants. 48   Given that the reported incidence of postpartum bleeding without anticoagulant use ranges from 4% to 22% of all pregnancies, 49-51   we suspect that pregnancy-related bleeding in women using anticoagulants is generally underreported. To complicate things even further, there is no uniform definition of postpartum hemorrhage, and for anticoagulant-related bleeding events in pregnancy and the postpartum period, commonly used classification criteria may not suffice. Therefore, a proposal for classification of severity of such bleeding events was recently made by an international multidisciplinary group of clinical investigators and clinicians and also published on behalf of the ISTH subcommittee for control of anticoagulation. 52  

With regard to accessibility to neuraxial analgesia and anesthesia, choice of the required interval to allow neuraxial analgesia or anesthesia (ie, time intervals of 12 hours for prophylactic-dose LMWH and 24 hours for higher-dose LMWH) is very conservative and strictly followed. Alternative forms of pain relief during spontaneous labor are also available as less effective but secondary options, such as patient-controlled analgesia with remifentanil, although we acknowledge the need to pay attention to the potential for neonatal respiratory depression as a disadvantage of this method. 53   For an emergency cesarean section, the only alternative is general anesthesia. Actual accessibility to neuraxial analgesia in women using LMWH seems reassuring. Preliminary results of the thrombosis prophylaxis Highlow study involving 587 women (registered at www.clinicaltrials.gov as #NCT01828697) showed that the proportions of patients using LMWH during pregnancy with a time interval that was too short to allow neuraxial anesthesia were 2.4% in patients receiving prophylactic-dose LMWH and 5.1% in patients receiving higher-dose LMWH. 54   If there is no obstetric indication for an induced delivery, we instruct women to not inject LMWH as soon as labor starts with either contractions or rupture of the membranes. Active management of the third stage of labor remains necessary to minimize the risks of obstetric hemorrhage and is standard practice.

Data on the potential disadvantages of planned delivery are conflicting. Observational data have indicated consistent associations between induction of delivery and increased interventions, including cesarean section. 55,56   These results are probably largely driven by indication bias. In the past decade, data of randomized trials for various indications have provided evidence to suggest that if there is a good indication for induced delivery, the increased cesarean section rate is not observed (or it can sometimes even be protective). 57,58   The crucial question therefore is whether the assumed benefits of planned delivery in this setting are such a good clinical indication. These trials did not investigate other subtler outcomes that are changed by medical interventions, including the potential programming effects of late relative preterm birth, where even in the term period, subtle effects on school performance were found, 59   and patient experiences.

In women at very high risk for extension or recurrent VTE (arbitrarily within 1 month before expected delivery), we consider the risks of a prolonged period without anticoagulation to be higher, and therefore, we schedule a planned delivery so that the duration of time without anticoagulation can be minimized. Those at the highest risk of recurrence (proximal DVT or PE within 2 weeks before delivery) can be switched to therapeutic IV UFH, which is then discontinued 4 hours before the expected time of delivery or the use of neuraxial anesthesia.

After the unsuccessful filter retrieval, therapeutic-dose LMWH was switched to full-dose DOAC. The presentation of the PE, together with the filter being present permanently as well as the patient’s preferences, led to the shared decision to continue some form of anticoagulation, and we switched to low-dose DOAC for secondary VTE prevention 4.5 months after the PE. She did not develop symptoms of postthrombotic syndrome, nor did she have residual pulmonary symptoms. She gradually recovered from her neurological trauma, and 3 years later, she had regained her old functional level and was working. Her daughter was also doing very well.

Anticoagulation should be restarted after delivery as soon as possible, depending on the amount of estimated vaginal blood loss and the type of delivery. Generally, restarting therapeutic-dose anticoagulation 12 to 24 hours after delivery is feasible, but this period should be longer if hemostasis is not adequate. If the anticipated interval is >24 hours because of bleeding, a prophylactic dose 24 hours after delivery should be considered. In most women in whom the intention is to stop anticoagulation 6 weeks after delivery, continuation with therapeutic-dose LMWH until 6 weeks postpartum (or until discontinuation if VTE occurred in late pregnancy) is the most practical option. In women who will continue anticoagulation indefinitely and who plan to breastfeed their babies, we first restart LMWH and initiate the first loading dose of VKAs at least 1 day later. LMWH can be discontinued after at least 3 days of VKAs and as soon as the international normalized ratio is >2.0. It is important to reassure women that they can breastfeed during use of either LMWH or VKAs, particularly nonlipophilic types such as acenocoumarol and warfarin ( Table 1 ). 15,60,61   Alternatively, if women do not plan to breastfeed, LMWH can be replaced by a DOAC. We treat women with therapeutic-dose LMWH until 6 weeks postpartum and for a minimum duration of 3 months. If the pregnancy-related VTE was the first episode, we advise discontinuation of anticoagulation after 3 months total duration or after 6 weeks postpartum. In the recent European Society of Cardiology 2019 PE guideline, pregnancy is considered a minor transient risk factor leading to an intermediate risk (3% to 8% per year) of recurrence after discontinuation of anticoagulants, with a recommendation to consider extending anticoagulation in women with pregnancy-related VTE. 46  

Two years later, the patient consulted us because she wanted to become pregnant again. Because she had a history of pregnancy-related VTE, we advised antepartum and postpartum prophylaxis with LMWH. She was enrolled in the Highlow study, an international, multicenter, randomized controlled trial comparing low-dose with intermediate-dose LWMH for the prevention of pregnancy-related recurrent VTE, and she was treated with the intermediate dose. There were no major issues during this pregnancy, and she delivered a healthy girl. She continued LMWH prophylaxis until 6 weeks after delivery.

After pregnancy-related VTE, the risk of recurrence during subsequent pregnancies is 6% to 10% if no prophylaxis is administered. 62-64   The risk of recurrence is influenced by the factors present during the first VTE, as is the case for nonpregnant patients. Women who have had a single episode of VTE that was associated with a transient nonhormonal risk factor are at low risk of recurrence during pregnancy. 62,63,65   For these patients, the burden of subcutaneous injections, side effects, and risk of peripartum bleeding may not outweigh the high number needed to treat during pregnancy, and only postpartum thromboprophylaxis for 6 weeks is recommended. 15   In all other pregnant women with a history of VTE (ie, unprovoked VTE or VTE provoked in the presence of minor or hormonal risk factors or recurrent VTE), both antepartum prophylaxis and postpartum prophylaxis are suggested. 15   Given that the increased risk of VTE is similar across trimesters, we initiate LMWH prophylaxis as soon as a pregnancy test is positive, and to do so, we prescribe a starting dose of LMWH preconceptionally. The optimal dose of LMWH for prevention of pregnancy-related recurrent VTE is unknown. Retrospective cohort studies have suggested high recurrence rates of VTE ranging from 2.5% to 8% despite thromboprophylaxis, 63,64 , 66-69   but data are conflicting. 70,71   A Cochrane review concluded that there is insufficient evidence on which to base recommendations for thromboprophylaxis during pregnancy or the early postnatal period, with the small number of differences detected in this review being largely derived from trials that were not of high methodological quality. 72   Whereas the American College of Chest Physicians 2012 guideline suggests use of either a low or intermediate prophylactic dose (half of therapeutic) with no preference for 1 dose over the other, 73   the 2018 ASH guideline on VTE suggests against an intermediate dose antepartum and indicates no preference for a prophylactic or intermediate dose postpartum. 15   The Highlow study comparing low-dose with intermediate-dose LWMH for the prevention of pregnancy-related recurrent VTE is ongoing and will provide valuable information. 74   To date, >1070 patients have been recruited, and results are expected in 2021 to 2022.

Women who use anticoagulants outside of pregnancy should, if receiving DOACs, be switched to VKAs preconceptionally. 42   As soon as the pregnancy test is positive, VKAs should be switched to therapeutic-dose LMWH, and the effect of VKAs can be reversed by oral vitamin K supplements. 42  

Finally, it is very important that treating physicians counsel all young women with an episode of VTE about future pregnancies, as well as other related issues (ie, the 5 Ps): period, pill, prognosis, pregnancy, and postthrombotic syndrome. 75  

The management of pregnancy-related VTE is based on extrapolation from the nonpregnant population, and clinical trial data on the optimal treatment are scarce. Our approach, as well as alternatives, is summarized in Table 2 . LMWH in therapeutic doses is the treatment of choice during pregnancy, and anticoagulation should be continued until 6 weeks after delivery, for a minimum total duration of 3 months. Whether dosing should be based on weight or anti-Xa level is unknown, and practice differs among centers. There is limited experience with thrombolysis and IVC filter use in pregnant women, but in some cases, these interventions must be considered. Management of delivery requires a multidisciplinary approach. With some limitations, neuraxial analgesia is possible, and spontaneous vaginal delivery is our preferred option in obstetric patients who need therapeutic anticoagulation. Prevention of recurrent VTE in subsequent pregnancies is indicated in most women with a history of VTE, and results from a large randomized trial investigating the optimal dose are expected in the coming years.

How I treat pregnancy-related VTE and a summary of alternatives

Our approach and alternatives are justified in the full text.

aPTT, activated partial thromboplastin time; INR, international normalized ratio.

The authors acknowledge K.P. van Lienden for his involvement with case 2 and critical review of the manuscript.

Contribution: S.M. and W.G. wrote the manuscript.

Conflict-of-interest disclosure: S.M. is the principal investigator of the Highlow study and reports grants and fees paid to her institution from GlaxoSmithKline, Bristol-Myers Squibb/Pfizer, Aspen, Daiichi Sankyo, Bayer, Boehringer Ingelheim, Sanofi, and Portola. W.G. is the principal investigator of the DRIGITAT study ( https://www.trialregister.nl/trial/6475 ) and reports an unrestricted grant from Roche Diagnostics paid to his institution for in-kind delivery of materials.

Correspondence: Saskia Middeldorp, Department of Vascular Medicine, Amsterdam Cardiovascular Sciences, Amsterdam University Medical Centers, Meibergdreef 9, Amsterdam, 1105 AZ, The Netherlands; e-mail: [email protected] .

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pregnancy health center / pregnancy a-z list / what does minus 1 mean in labor article

What Does Minus 1 Mean in Labor?

• Medical Author: Karthik Kumar, MBBS
• Medical Reviewer: Pallavi Suyog Uttekar, MD

What is the Bishop score?

What do bishop scores mean, what is the safest fetal position to deliver a baby.

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Fetal station indicates the position of the baby's head in the mother’s pelvis and indicates the progress of labor . This is represented by a number between -5 and +5. It is an imaginary line drawn between the two opposite bones of the pelvic arch (called ischial spines). 

The baby is said to be in zero station when it reaches this imaginary line. The baby is in a minus station when it is above this imaginary line. The baby is in a plus station when it is below the imaginary line.

• Zero station: Indicates that the presenting part (usually the baby's head) is parallel to the spines.
• Negative value (-5 to -1): Indicates that the baby’s head is not engaged in the pelvis.
• Positive value (0 to +4): Indicates that the baby's head is moving down the pelvis, whereas a +5 indicates that the baby is crowning (being born).

It is common for a baby to be at -3, -2 or -1 during labor . Ideally, a mother should wait until the baby's head is engaged in the pelvis (at least 0) before pushing, but it is even better to wait until the baby is lower in the pelvis. This will shorten the mother's pushing time and reduce the likelihood of the birth canal swelling.

Fetal station is a component of the Bishop score, which assists doctors in determining whether induced labor , Cesarean delivery, or forceps delivery is required.

The Bishop score is used to determine the condition of the cervix and position of the baby in the pelvis. During a vaginal examination, the following factors are assessed to determine the total score:

• Cervical dilation: This is the measurement of the cervix opening. It is measured in centimeters ranging from 0-10.
• Cervical effacement: This is a measurement of the thinness and shortening of the cervix as it opens. It is measured as a percentage ranging from 0%-100%.
• Cervical consistency: This refers to the sensation of the cervix. A hard cervix, like the tip of the nose, indicates an unfavorable cervix. A softer cervix will feel like the bottom lip or the inside of the cheek.
• Cervical position: The cervix is usually high and facing back in a posterior position behind the baby's head before labor begins. As the body prepares for labor, the cervix lowers and moves more into a forward-facing anterior position.
• Fetal station: This is the measurement of the baby's position in relation to the pelvic ischial spines. The ischial spines are labeled "0," whereas the area above and below the spine is labeled "+" and "-."

A high Bishop score indicates a greater possibility of successful induction of labor. A low Bishop score indicates a lower chance of successful induction of labor. A woman with a low score of 1 is unlikely to go into labor for at least 3 weeks. A woman with a score of 10 or higher is likely to go into labor within a few days.

Although the Bishop score was originally used to assess the likelihood of vaginal delivery in women who had previously given birth (multiparous), it is now also used to assess the likelihood of vaginal delivery in women who had never given birth (nulliparous) and are being considered for induction of labor.

• If the Bishop score is 8 or higher, there is a good chance of vaginal delivery, and the cervix is said to be favorable for induction.
• If the Bishop score is 6 or less, the chances of vaginal delivery are slim, and the cervix is considered unfavorable for induction.

The best position for the baby as they approach birth is occiput anterior (OA) or vertex presentation. The baby enters the pelvis with its head down and chin tucked and facing the mother's coccyx . In this position, the head is pointing to the birth canal. It has two presentations:

• Face and brow presentation: The baby will remain in the OA position, but their face, instead of their head, will be pointing toward the birth canal. This occurs when the chin is not tucked against the chest and points outward, this occurs. The doctor can detect this position during a vaginal examination by feeling the baby's bony jaws and mouth. The baby will be in the OA position with their forehead pointing toward the birth canal during brow presentation.
• Compound presentation: The baby is facing forward with one arm lying along the head and pointing toward the birth canal. The arms may slide back during the delivery process, but if they do not, special care must be taken to deliver the baby safely.

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The Pregnant Workers Fairness Act: What U.S. Employers Need to Know

• Cynthia Thomas Calvert

A new federal law requires organizations with 15 or more employees to accommodate all health needs at work arising from pregnancy, childbirth, and related conditions.

This year in the U.S., the Equal Employment Opportunity Commission (EEOC) issued final regulations to implement the Pregnant Workers Fairness Act (PWFA), a new federal law that requires the federal government as well as private, state, and local employers with 15 or more employees to accommodate all health needs at work arising from pregnancy, childbirth, and related conditions. The authors, who have counseled and trained hundreds of employees, businesses, and attorneys on the new law, outline what leaders need to know to support their pregnant workers while avoiding unnecessary EEOC charges and litigation.

The ground rules of pregnancy accommodation have recently shifted significantly. In April, the Equal Employment Opportunity Commission (EEOC) issued final regulations to implement the Pregnant Workers Fairness Act (PWFA), a new federal law that requires employers to make reasonable accommodations for pregnancy, childbirth, and related medical conditions.

• LM Liz Morris is the incoming co-director of the Center for WorkLife Law at the University of California, College of the Law, SF.
• CC Cynthia Thomas Calvert is senior advisor at WorkLife Law and the principal of Work+Family Insight, an HR consulting firm.

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