Why Are Abnormal Presentations Dangerous for the Fetus?

During pregnancy, there are several factors that can potentially lead to complications for the mother, the fetus, or both. One of these factors is the fetus’s position in the womb. The most common position – the cephalic position – is also generally considered the safest under most circumstances. Any other position is classified as “abnormal” and can potentially increase the risks for the mother and the child.

It is important to emphasize that an abnormal fetal presentation is not inherently dangerous. In many cases, the fetus will move into the cephalic position as it develops during pregnancy, and no ill effects will result. It is also very possible – and relatively common – for a fetus to go through the birth canal in an abnormal presentation without any complications. However, an abnormal presentation can be dangerous, and doctors have a duty to affirmatively address any and all potential risks when an abnormal presentation occurs.

What Is Abnormal Presentation?

In order to understand the potential risks associated with abnormal presentation, it is first necessary to understand when an abnormal presentation occurs. Once you understand why a presentation is abnormal, it is much easier to understand the risk factors associated with the fetus’s orientation in the womb.

As we mentioned in the introduction, fetuses typically present in the cephalic position. If all other presentations are considered abnormal, then this would be the “normal” or most-common way in which a fetus is oriented during gestation. As the Cleveland Clinic explains:

“Ideally for labor, the baby is positioned head-down, facing the mother’s back with the chin tucked to its chest and the back of the head ready to enter the pelvis. This position is called the cephalic presentation. Most babies settle into this position within the 32nd to 36th weeks of pregnancy.”

In this presentation, the fetus is ideally positioned to move through the mother’s birth canal without complications, such as an arm becoming contorted or a shoulder getting stuck behind the mother’s pelvic bone. While it is still certainly possible for complications to occur – particularly if the fetus is abnormally large or if delivery becomes prolonged – cephalic presentation is generally the safest and least-difficult way for a child to be born.

If a fetus is not in the cephalic position, then this is considered to be an abnormal presentation. The types of abnormal presentations include:

• Cephalic posterior presentation, which is similar to cephalic presentation except the fetus is facing the mother’s abdomen instead of her back.
• Compound presentation, which occurs when multiple parts of the body are positioned to enter the birth canal at the same time, such as the head and an arm or leg.
• Complete breech presentation, which is characterized by the fetus being in a “sitting” position with legs folded and arms crossed.
• Face or brow presentation, which is characterized by a backward-bending neck such that the face or brow is directly facing the birth canal.
• Footling breech, which is similar to a complete breech except the legs are extended toward the birth canal.
• Frank breech, which is also similar to a complete breech except the hips are flexed and the knees are extended.
• Shoulder presentation, which is characterized by the fetus being positioned at such an angle that one of the shoulders is positioned directly above the birth canal.
• Transverse lie, which is characterized by the fetus’s body lying across the mother’s uterus rather than being in the more typical fetal position.

In many cases, an abnormal presentation can either be “full” or “incomplete.” A full abnormal presentation occurs as described in the list above, while an incomplete abnormal presentation involves some sort of variation, such as only one leg being extended in the case of an incomplete footling breech.

Additionally, some types of abnormal presentations are further broken down based on more minute characteristics of the fetus’s position. For example, a face presentation can be either (i) mentum anterior, in which the chin is facing forward, (ii) mentum posterior, in which the chin is facing the mother’s back, or (iii) mentum transverse, in which the chin is facing to one side.

What Are the Risks Associated with Abnormal Presentation?

While individual forms of abnormal presentation can carry some specific risks, there is also a long list of potential complications associated with abnormal presentation generally. These potential complications are largely linked to additional challenges the fetus faces in entering and passing through the birth canal. For example, some of the most common risks associated with abnormal presentation include:

• Prolonged Labor – Abnormal presentation can lead to prolonged labor, and this can increase various risks for both the mother and the fetus. Two of the most significant risks associated with prolonged labor are (i) excessive bleeding for the mother and (ii) oxygen deprivation for the fetus.
• Edema – Edema occurs as a result of excess fluid accumulation in the body. When a fetus presents abnormally, trauma during delivery can cause edema, and this can potentially restrict the fetus’s airway or blood flow or lead to physical deformations.
• Hemorrhage – Trauma during a difficult delivery can lead to internal bleeding, which is referred to in medical terms as a hemorrhage. Internal bleeding can present various risks for the fetus; and, when a hemorrhage occurs in the brain, this can potentially have serious long-term or permanent consequences.
• Facial Trauma – Facial trauma is most common with face and brow presentations, but it can occur as a result of a difficult delivery caused by other abnormal presentations as well. Injuries to the nose, eyes, jaw, nerves, and muscles in the face can vary in terms of their severity, with some forms of facial trauma having the potential to cause permanent deformation.
• Misshapen Skull – A fetus’s skull is still forming at the time of childbirth, and physical pressure applied to the head during delivery as the result of the abnormal presentation can lead to a misshapen skull, also known as skull molding.
• Shoulder Dystocia – Shoulder dystocia occurs when the fetus’s shoulder gets stuck behind or above the mother’s public bone as a result of an abnormal presentation. Shoulder dystocia can lead to brachial plexus injuries and bone fractures for the fetus, and can potentially cause perineal tears, uterine rupture, and excessive bleeding for the mother.
• Bone Fractures – Different abnormal presentations can present heightened risks for various types of bone fractures as the fetus attempts to pass through the birth canal. This includes facial fractures, skull fractures, clavicle fractures, and fractures in the arms and legs.
• Spinal Cord Injuries (SCI) – Spinal cord injuries can also result from trauma during childbirth, whether as a result of squeezing or contortion or as a result of the fetus’s back impacting against other body parts or the mother’s pelvic bone. This includes nerve damage, spinal fractures, and other forms of SCI.
• Compromised Ventilation – Various forms of abnormal presentation can also cause respiratory complications, including compromised ventilation. When a child is born from an abnormal presentation, it becomes particularly important to monitor the child’s heart rate and breathing for signs of distress.
• Heart Complications – Oxygen deprivation, limited blood flow, and various other issues related to abnormal presentations can cause heart complications as well. This includes a reduced heart rate, which can result in insufficient oxygen supply to the brain and other issues if not treated promptly.
• Hypoxic–Ischemic Encephalopathy (HIE) – Hypoxic-ischemic encephalopathy is a potentially serious condition that results from an inadequate supply of oxygen, and it can be caused by complications of delivery resulting from an abnormal presentation. Complications of HIE can include developmental delays, behavioral disorders, seizure disorders, and cerebral palsy (CP).
• Brain Damage – In addition to HIE, trauma, and other complications, resulting from the abnormal presentation, can cause serious and potentially irreversible brain damage as well. Along with developmental delays, behavioral disorders, seizure disorders, CP, and other forms of palsy, brain damage during delivery can cause vision and hearing impairments, learning disabilities, microcephaly, and several other life-altering effects.

What Is the Doctor’s Duty When a Fetus Presents Abnormally?

With modern medical knowledge and technology, abnormal presentation is easy to diagnose. As a result, a doctor’s first duty is to determine when a fetus is presenting abnormally and to discuss the associated risks with the mother promptly. At this stage, the doctor should also assess the likelihood of the fetus transitioning to the cephalic position before the mother goes into labor, taking into consideration the fetus’s size, the mother’s expected due date, and other pertinent factors.

In some cases, it will be possible to manually manipulate the fetus in order to place it into the cephalic position. When this is the case, the mother’s doctor should generally take this step, unless there are countervailing considerations that warrant a different approach. If it is not possible to manually manipulate the fetus, then the doctor should make a determination as to whether some other form of intervention is required and consult with the mother as necessary.

Depending on the specific type of abnormal presentation at issue, it may be necessary for the doctor to recommend a cesarean section (C-section) delivery or to induce labor in order to mitigate the risks of a delayed or prolonged vaginal delivery. If the decision is made to move forward with vaginal delivery, then both the mother and the fetus should be carefully monitored throughout, and appropriate testing should be performed promptly following delivery in order to diagnose any injuries or complications that may require treatment.

What If a Doctor Fails to Prevent Injuries or Complications Due to an Abnormal Presentation?

If a doctor fails to take appropriate steps to prevent injuries or complications due to an abnormal presentation, then the doctor can be held liable for malpractice. Unfortunately, birth injuries caused by medical negligence and malpractice are not uncommon, and many new parents find themselves in a situation in which they need to take legal action. If your child presented abnormally and suffered a traumatic injury, brain injury, or other complication as a result, we strongly recommend that you consult with an attorney about your family’s legal rights.

Speak with a Trusted Injury Lawyer at Berkowitz Hanna

At Berkowitz Hanna, we have decades of experience helping parents in Connecticut recover financial compensation for birth injuries caused by malpractice. To schedule a free, no-obligation consultation with one of our attorneys, call us directly or contact us online today.