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How Abnormal Fetal Lie or Malpresentation Is Identified

Written by Berkowitz

pregnant woman holding baby bump

When a fetus is in the womb, its positioning can greatly impact the risk of complications arising during pregnancy, labor, and delivery. In the majority of pregnancies, the fetus’s positioning is as it should be, and no additional risks are involved. However, this is not always the case, and some expecting mothers can face unexpected challenges due to what is known as abnormal fetal lie or malpresentation.

Understanding the Terminology: Lie, Position, and Presentation

In order to understand the risks associated with abnormal fetal positioning, it is first necessary to understand the relevant terminology. While we have used the term “positioning” thus far, doctors actually use three different terms to describe various aspects of a fetus’s positioning in the womb:

  • Position – Position refers to the direction of the fetus’s body in relation to the mother’s front or back. It is most common and generally safest for the fetus to be facing rearward, toward the mother’s back. If the fetus is positioned facing forward, toward the mother’s belly button, this can increase the risk of certain types of complications in some cases.
  • Presentation – Presentation refers to the part of the fetus’s body that is facing downward toward the birth canal. Head-first presentation is most common and generally safest, while shoulder-first, arm-first, leg-first, and buttocks-first presentation can all increase the risk of trauma and oxygen deprivation during labor and delivery.
  • Lie – Lie refers to the direction in which the fetus’s body lies across the mother’s cervix. The longitudinal lie is most common and generally safest, and this is when the fetus’s body is positioned vertically (ideally with the head presenting first). The alternatives, transverse lie and oblique lie, can greatly increase the challenges of performing a safe vaginal delivery.

Based on these definitions, you can see that the “normal” positioning of a fetus involves facing rearward with head-first presentation and longitudinal lie. Any other positioning is considered “abnormal,” and while this does not necessarily mean that the mother and/or fetus will experience additional challenges during labor and delivery, the risk is higher. The degree of additional risk depends on the fetus’s specific positioning in the womb and whether (and to what extent) the fetus’s position, presentation, and/or lie can be adjusted during pregnancy.

Identifying Abnormal Fetal Lie or Malpresentation

Given the potential risks associated with an abnormal fetal lie and malpresentation, identifying issues with a fetus’s position, presentation, and/or lie during pregnancy is critical. The obligation to identify abnormal fetal lie or malpresentation falls on the mother’s doctor, and all obstetrician-gynecologists (OB-GYNs) should be well-versed in the procedures for identifying and addressing issues related to a fetus’s position, presentation, or lie during pregnancy.

In broad terms, the steps for identifying abnormal fetal lie and malpresentation are as follows:

Step #1: Assessing Maternal and Fetal Risk Factors

One of the first steps toward identifying abnormal fetal lie or malpresentation is to assess the maternal and fetal risk factors that are present with regard to a particular pregnancy. While testing should generally be conducted to identify the fetus’s position, presentation, and lie regardless of whether (and to what extent) any of these risk factors are present, assessing risk factors can be essential to uncovering issues early and intervening in time to prevent unnecessary complications. Some of the most common risk factors associated with abnormal fetal lie and malpresentation include:

  • Being pregnant with multiples (e.g., twins or triplets)
  • Having prior pregnancies
  • Likelihood of premature birth
  • Uterine septa and other uterine abnormalities
  • Placenta previa and other placental abnormalities
  • Polyhydramnios and other fetal abnormalities

Each of these risk factors may have its own set of signs and symptoms; and, with this in mind, doctors must carefully and comprehensively examine expecting mothers at various stages throughout their pregnancies in order to determine whether any risks for an abnormal fetal lie, malpresentation, or other complications may be present. For example, common signs and symptoms of polyhydramnios (which typically occur in the second and third trimesters) include:

  • Blood type incompatibility
  • Congenital abnormalities
  • Indigestion, constipation, producing little urine during pregnancy
  • Maternal diabetes
  • Swelling in the legs
  • Tightness in the stomach

While it is incumbent upon doctors to identify signs and symptoms such as these and take appropriate action in response, it is important for expecting mothers to know when certain feelings and conditions can potentially indicate the need for medical treatment as well. However, as expecting mothers are often told to anticipate a broad range of symptoms and feelings during pregnancy, it can be difficult to know when it is time to call your doctor. Thus, the obligation once again falls on expecting mothers’ medical professionals to provide clear guidance as to when some form of medical intervention may be necessary.

Step #2: Checking the Fetus’s Positioning in the Womb

After assessing all pertinent maternal and fetal risk factors, the next step for identifying abnormal fetal lie and malpresentation is simply to check the fetus’s positioning in the womb. This can be done in a number of different ways. Most commonly, ultrasounds are used to check fetal positioning, and in some cases, OB-GYNs may manually check a fetus’s positioning as well. Regardless of the method (or methods) used, accuracy is obviously of utmost importance, and doctors must avoid rushing in order to ensure that they are able to provide an accurate diagnosis of the fetus’s position, presentation, and lie.

Step #3: Continuing to Monitor the Fetus’s Position, Presentation, and Lie

As a fetus continues to develop during pregnancy, the fetus can shift its positioning in the womb. As a result, checking for abnormal fetal lie and malpresentation is not a one-time event. Instead, a fetus’s positioning should continue to be monitored throughout the mother’s pregnancy, with due consideration being given to any signs or symptoms that suggest the fetus may have shifted (or may be at risk for shifting) to an unfavorable position, presentation, or lie in the mother’s womb. When performing ultrasounds to check for abnormal fetal lie or malpresentation, doctors should generally check for any other relevant concerns (e.g., uterine or fetal abnormalities) as well.

What Should My Doctor Do after Identifying Abnormal Fetal Lie or Malpresentation?

If your doctor identifies abnormal fetal lie or malpresentation, what are (or what should be) the next steps? The answer to this question depends on factors including the current stage of your pregnancy and the specific type of abnormal fetal lie or malpresentation that has been identified. Any other risks either associated with or resulting from your fetus’s position, presentation, or lie must be taken into consideration as well – particularly if they indicate the possible need for an emergency cesarean section (C-section) delivery.

In many cases, it will be possible to manually adjust the fetus’s positioning in the womb. Referred to as an external cephalic version (ECV), this procedure tends to be most effective between the 36th and 38th months of pregnancy. In other words, it may not be necessary or prudent to perform an ECV right away, depending on when the fetus’s abnormal fetal lie or malpresentation is identified. In some circumstances, fetuses will naturally shift to the ideal positioning and no intervention will be necessary. However, it should not be assumed that this will happen; and, if it is not yet time to perform an ECV, careful monitoring of the fetus should continue.

It is also important to note that performing an ECV will not be appropriate in all circumstances. In particular, if the mother has experienced ruptured membranes, uterine abnormalities, antepartum hemorrhage, or a prior C-section delivery, then an ECV may not be advised.

If the fetus is showing signs of distress – or if the risks associated with the fetus’s position, presentation, and/or lie are significant and an ECV is either not viable or not successful – then an emergency C-section delivery may be necessary. Failure to timely perform an emergency C-section can put both the mother and the fetus at risk, and can potentially lead to long-term cognitive and/or developmental complications. When the circumstances of pregnancy call for an emergency C-section, the mother’s doctor should promptly explain the risks of both moving forward and not moving forward with the procedure, and it should be clear that the mother understands both sets of risks before she is asked to make a decision.

What If My Doctor Failed to Identify Abnormal Fetal Lie or Malpresentation?

If your doctor failed to identify abnormal fetal lie or malpresentation, and if this failure led to complications during your pregnancy, labor, or delivery, then you may have a claim for medical malpractice. Unfortunately, these types of medical mistakes are far more common than they should be. Despite being both easily detectable and easily remedied in many cases, abnormal fetal lie and malpresentation frequently lead to preventable birth injuries.

With today’s modern medicine, abnormal fetal lie or malpresentation should never come as a surprise when a mother has received care during her pregnancy. Likewise, when an issue with a fetus’s position, presentation, or lie has been identified, there is no excuse for anything less than total preparedness. As the parent of a child who has suffered harm due to failure to diagnose or remedy abnormal fetal lie or malpresentation, you may be entitled to compensation for the financial and non-financial costs of your child’s condition, and you should speak with a dedicated injury lawyer about filing a claim to recover your family’s current and future losses.

Speak with a Skilled Injury Lawyer at Berkowitz Hanna

If you would like more information about filing a malpractice claim for complications resulting from abnormal fetal lie or malpresentation, we strongly encourage you to speak with one of our experienced injury lawyers. To schedule a free and confidential consultation at your convenience, call us directly or request an appointment online today.