Abnormal fetal position

Disease Description (Causes and Symptoms)

• Definition: A condition in which the fetus is not in the normal cephalic presentation (head down), such as breech, transverse, face, brow, or compound presentation.
• Pathophysiology and causes:
  • Fetal factors: Small fetus, anomalies (anencephaly, hydrocephalus, etc.), chromosomal abnormalities
  • Uterine and placental factors: Placenta previa, multiple pregnancy, polyhydramnios (uterine expansion), or severe uterine restriction (uterine anomalies, intrauterine adhesions)
  • Maternal factors: Narrow pelvis, pelvic tumors
  • Rotation has not occurred by the end of pregnancy
• Main symptoms: Usually asymptomatic (the mother may notice a change in the location of fetal movements, or palpation of the abdomen may reveal the head above or beside the umbilicus). Complications may include umbilical cord prolapse (particularly with footling breech or transverse presentation), prolonged labor, and difficult labor.
• Diagnosis: Confirmed by abdominal palpation (Leopold maneuvers), vaginal examination, and ultrasound. Evaluation in late pregnancy, especially at 36–37 weeks, is important.

Treatment

• General principles
  • Before 37 weeks of pregnancy, spontaneous rotation may still occur, so observation is often recommended.
  • If malpresentation persists after 37 weeks, a delivery plan (cesarean section or planned vaginal delivery) needs to be established.
• External cephalic version (ECV)
  • Indications: Singleton pregnancy, stable fetus, adequate amniotic fluid volume, and appropriate placental position (placenta previa is a contraindication); usually attempted around 36–37 weeks of pregnancy.
  • Procedure: The fetus is rotated through the abdominal wall into a cephalic presentation. Fetal heart rate monitoring is performed, and tocolytics may be used if necessary.
  • Success rate: Approximately 40–60% (varies depending on the conditions). Complications, such as fetal distress, bleeding, and preterm labor, are possible but rare.
  • Contraindications: Placenta previa, multiple pregnancy (generally a contraindication), abnormal fetal heart rate, risk of preterm labor or uterine rupture, severe uterine anomalies, etc.
• Determining the mode of delivery
  • Cesarean section: Often recommended when breech presentation persists after 37 weeks, in high-risk presentations (transverse, brow, or face presentation in cases where vaginal delivery is impossible or dangerous), or for breech presentation in a woman giving birth for the first time.
  • Planned vaginal delivery: May be considered when conditions are met (singleton pregnancy, complete or frank breech, appropriate estimated fetal weight, adequate pelvis, an experienced obstetrician, immediate availability of cesarean section, etc.).
• Management during labor: Continuous fetal heart rate monitoring, preparation for umbilical cord prolapse, and readiness to perform an immediate cesarean section if necessary.
• Medications and procedures: Tocolytics (to assist ECV), anesthesia (local or general sedation may be used during ECV), and anesthesia and surgery for cesarean section.
• Precautions, risk of complications, and self-care
  • Complications: Umbilical cord prolapse, cord compression, fetal injury (rare), and possible association with postpartum hemorrhage (depending on the circumstances).
  • Self-care: Visit the hospital immediately if fetal movement decreases, attend regular ultrasound examinations and outpatient visits, and keep records of medications and test results.
  • The mother should be aware that ECV may cause pain, discomfort, and, rarely, bleeding or uterine contractions.

Outpatient Visit Checklist (Including Preparation Items and Example Questions)

• Items to prepare (things to bring)
  • Recent prenatal ultrasound images and reports (presentation, estimated fetal weight, placental position, and amniotic fluid volume)
  • List of currently used medications and health supplements
  • Previous pregnancy and delivery history (including any previous cesarean section)
  • Blood type and antibody test results, if available, and basic test results
  • Record of changes in fetal movement (when they began and changes in frequency or strength)
• Points to check during the visit
  • Gestational age, fetal heart rate, and whether the fetal presentation has changed
  • Whether placenta previa or multiple pregnancy is present, and the amniotic fluid volume
  • Delivery plan (possibility and timing of attempting ECV, and whether cesarean section is planned)
• Simple example questions to ask the doctor directly during the outpatient visit
  • "What is my fetus's current presentation? Could you show me the ultrasound results?"
  • "Are the conditions suitable for attempting ECV? What are the success rate and risks?"
  • "If the breech presentation persists after 37 weeks, what delivery plan would you recommend?"

General Example Questions to Ask the Doctor

• "What are the side effects and risks of this medication (or procedure)?"
• "What is the prognosis in our case (the predicted delivery outcome)?"
• "Are there any precautions I should take regarding lifestyle habits (exercise, diet, and sexual activity)?"
• "What is the next plan if ECV fails?"
• "Do I need to schedule a cesarean section in advance? What complications are expected with the surgery?"

Example Questions Tailored to the Condition

• "What specific type of presentation does my fetus have (frank breech, complete breech, feet-down, etc.)? What delivery recommendation applies to it?"
• "If you recommend ECV, what are the expected success rate and timing, and what are the contraindications (such as placenta previa or multiple pregnancy)? How will pain be managed and monitoring performed during the procedure?"