Overview

Most expecting parents are aware that babies are ideally head down. As you get closer to your due date, your baby’s position can significantly impact your labor and birth. Few doctors and midwives have training and experience in vaginal breech birth. As a result, most mothers with a breech baby will require a cesarean delivery. Your baby’s position is much more nuanced than being head down or breech. For a vaginal birth, it isn’t a straight shot for your baby to maneuver through the birth canal. The direction they face, whether their head is extended, and other details of their position can lead to a shorter, easier, or less painful birth.

As you get closer to your due date, your doctor or midwife will monitor your baby’s position. You can also use easy methods at home to determine your baby’s position in your belly. Doctors and midwives have specific language to describe where your baby is, and it can get very confusing. When your care provider says your baby is LOP, after listening to this episode, you will know precisely what that means regarding how your baby is positioned and how it may influence your labor and birth.

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Why Your Baby’s Position Matters

Most expecting parents are aware that babies are ideally head down. As you get closer to your due date, your baby’s position can significantly impact your labor and birth. Few doctors and midwives have training and experience in vaginal breech birth. As a result, most mothers with a breech baby will require a cesarean delivery. Your baby’s position is much more nuanced than being head down or breech. For a vaginal birth, it isn’t a straight shot for your baby to maneuver through the birth canal. The direction they face, whether their head is extended, and other details of their position can lead to a shorter, easier, or less painful birth.

How to Determine Your Baby’s Position

You or your care provider can utilize a few methods to determine what position your baby is in. Some things can make it more difficult to feel your baby’s position, like the location of your placenta, weight, muscle mass, amount of amniotic fluid, and position your baby is in. Your baby has lots of space to stretch out early on. As your baby grows and has less room, it will likely be in the fetal position with its arms and legs tucked close to the body.

In the later part of your pregnancy, you and your doctor or midwife should be able to tell how your baby is positioned by gently feeling the outside of your belly. You should get a good idea of how your baby is situated by feeling their head, which will be firmer than its bottom. This is easier for a professional with a lot of hands-on experience. Some mothers may be able to easily figure out where their baby’s head and bottom are. If you have difficulty determining your baby’s position, ask your care provider to walk you through palpitating your belly. The later in your pregnancy, the easier it is to tell where your baby is and their position.

An advantage you have over your doctor or midwife is feeling movement from inside your belly. More substantial movements are likely kicks, and smaller movements are likely hands. The initial movements expecting mothers feel described as flutters, like butterfly wings flapping gently. These can start around 16 weeks or earlier if this is not your first baby. Many first-time moms don’t feel their baby moving until closer to week 20. As your pregnancy progresses and your baby grows, movements change from flutters to kicks and squirms. Eventually, you can feel and even see them kicking your belly from the outside. Knowing where their feet are can help you decipher how they are situated.

Your doctor or midwife can also utilize a stethoscope or a Doppler to find your baby’s heartbeat. Locating where the heartbeat is the loudest can indicate where your baby’s heart is. Your care provider can also use an ultrasound to view your baby’s position in your uterus.

Describing Your Baby’s Position in Pregnancy

Your baby’s position can be broken down into two parts, your baby’s presentation and which way they are facing.

Presentation

Four different presentations refer to what part of your baby is closest to the birth canal.

Cephalic is head down and divided into two categories depending on what part of your baby’s head is closest to the birth canal. Vertex is the most common cephalic position. Vertex means the highest point when the crown (top) of your baby’s head is down. Sinciput describes when another part of your baby’s head is presenting closest to the birth canal. This can be their forehead, brow, face, or chin.

Breech is the opposite of cephalic, where your baby’s bottom is closest to the birth canal. There are four classifications for breech positions. Complete breech is bottom down with legs crossed and knees up at the chest. Imagine sitting with your legs crossed, then bringing your knees to your chest. Frank breech is bottom down with their legs straight, so their feet are near their face. Picture sitting down with your legs straight before you and leaning forward until your head is against your knees. An incomplete breech combines a complete and frank breech when one leg is straight, and one is bent. Footling breech occurs when one or both feet are presenting closest to the birth canal.

Transverse is when your baby is sideways. Their bottom is on one side of your belly, with their head on the other. In this case, the part presenting that would come out first would be an arm, shoulder, or trunk.

Compound or complex presentation means that a limb presents with another body part. The most common compound presentation is a hand or arm with the baby’s head.

Facing

In addition to your baby’s presentation, there are classifications for the direction your baby is facing.

Anterior is when your baby faces your spine, and their back is against the outside of your belly.

Posterior describes your baby facing your belly with its back against your spine.

Transverse is when your baby is facing directly left or right. For example, if your baby is facing directly right, their back would be against the left side of your belly. This is separate from the transverse presentation when your baby is lying sideways.

When in Your Pregnancy is Your Baby’s Position Important?

Out of curiosity, you may want to know how your baby is situated in your belly throughout your pregnancy. Your baby will move around and change positions throughout their development. Your care provider isn’t concerned about your baby’s position until the last one or two months of your pregnancy. As your pregnancy progresses, your baby has less room to move around. Changing positions is much easier for your baby in week 25 than week 37.

A group of researchers analyzed over 18,000 ultrasounds to look at the frequencies of presentations in relation to gestational age. Unsurprisingly, most babies were not head down early on but did move into that position as pregnancies progressed. At 22 weeks, only 47% of babies are in a cephalic (head down) presentation, which increased to 94% at 36 weeks. Up to 24% of babies in a breech presentation will move into a cephalic presentation after 36-37 weeks. This data demonstrates that it really doesn’t matter what position your baby is in until the third trimester, and even then, your baby has a lot of time before the birth to get into an ideal position.

Fetal Positions in Labor

There is some other terminology your doctor or midwife may use to describe your baby’s position near labor. First, we need to define some terms. Occiput refers to the back of your baby’s head and is used for cephalic or head-down positions. Sacrum is a bone at the base of the spine, referring to your baby’s lower back. This is used in describing breech presentations. Dorso describes the way the scapula (shoulder blade) is facing. In shoulder presentations, the word dorso is used instead of occiput or sacrum.

The following positions describe a baby in a cephalic (head-down) position and refer to occiput. You could replace occiput with sacrum for a breech baby or dorso for a baby with a shoulder presentation. The directions left and right refer to your left or right. To envision these positions, look down at your belly and picture a clock. Your belly button is 12:00, and your spine is 6:00. The hour of the time on a clock is aligned with the back of your baby’s head.

Occiput Anterior (OA): the back of your baby’s head is direct to your belly button like they are looking towards your spine. 12:00

Right Occiput Anterior (ROA): moving clockwise, the back of your baby’s head is against your belly, to the right of your belly button. 1:30

Right Occiput transverse (ROT): the back of your baby’s head is directly against the right side of your belly. 3:00

Right Occiput Posterior (ROP): the back of your baby’s head is against your spine but is facing to the right of your spine. 4:30

Occiput Posterior (OP): the back of your baby’s head is direct to your spine. 6:00

Left Occiput Posterior (LOP): the back of your baby’s head is against your spine but is facing to the left of your spine. 7:30

Left Occiput Transverse (LOT): the back of your baby’s head is against the left side of your belly. 9:00

Left Occiput Anterior (LOA): the back of your baby’s head is against your belly, facing the left of your belly button. 10:30

The Ideal Position for Birth

The ideal position when your baby’s head emerges during birth is occiput anterior. This is when they are head down, the back of your baby’s head is against your pelvis, and they are directly facing your spine. In the birth canal, your baby can flex or extend their head. Flexion is when your baby’s head is tucked into the chest. This is ideal because it creates a smaller diameter as your baby’s head goes through your pelvis, making it easier for your baby to rotate. Extension is when your baby’s head is tilted up. You can imagine this if you sit or stand and look at the ceiling. A neutral or military position is when your baby’s head is straightforward, not flexed or extended.

Malpositions

Ideally, your baby is in an occiput anterior position with a flexed head at birth. This means they are head down, with the back of their head toward your belly, facing your spine, and their chin is tucked into the chest.

One study examined labor outcomes with cephalic (head down) babies in different positions and found malposition (any position other than anterior) at full dilatation was associated with a significantly increased risk of instrumental vaginal delivery, cesarean delivery, oxytocin administration before full cervical dilatation, episiotomy, severe perineal laceration, and maternal blood loss of more than 500 mL. The researchers also found a longer duration of the second (pushing) stage of labor for malpositioned babies.

Participants were divided into two groups with early or delayed pushing. In both groups, the mean length of the second stage of labor was shortest for anterior positions, longer in transverse, and longest in posterior. In the early pushing group, the mean length of the second stage was 2.2 hours for the anterior positions, 2.5 hours for transverse positions, and 3 hours for posterior positions. In the delayed pushing group, the mean length of the second stage was 3.1 hours for the anterior positions, 3.6 hours for transverse positions, and 3.8 hours for posterior positions.

Preference for the Left Side

Nearly every resource and most doctors and midwives will say that the ideal position for birth is anterior, facing toward your spine with the back of the head against your belly. As you enter and go through labor, there is a preference for your baby to be on the left side of your belly. There is a consensus that babies rotate clockwise during labor and birth. Look down at your belly and imagine the clock with 12:00 at your belly button and 6:00 at your spine. Ideally, your baby emerges at 12:00. If your baby starts on the left side, they don’t have a long distance to rotate clockwise to get to the occiput anterior (12:00) position.

Ideally, your baby is occiput anterior, left occiput anterior, or left occiput transverse before labor starts. If your baby is on the right side, it must rotate further if they are moving clockwise to reach the 12:00 position when crowning. While it is widely accepted that a left occiput anterior position is ideal, I did not find great evidence to support this.

One study examined whether there was an association between the fetal position at the onset of labor and the mode of delivery. This study included a total of 1,250 women. The prevalence of the different positions was 23.8% in an anterior position, 29.7% posterior, and 46.6% in a transverse (lateral) position. For babies who started labor in a left occiput anterior position, 49.7% had a spontaneous vaginal delivery. For babies in other positions, the rate was 53.3%. The study did not find evidence to support an association between a left occiput anterior position at the onset of labor and spontaneous vaginal delivery.

One study of over 1,500 women found fetal position changes common during labor. Regardless of the baby’s position at the start of examinations, most were occiput anterior at birth. Depending on what position the baby started in, 78-83% came out in an anterior position. Researchers also observed that women with an epidural had more occiput posterior fetuses at delivery (12.9% epidural versus 3.3% no epidural).

Putting Your Baby’s Position in Labor into Perspective

Your baby must undergo many movements to maneuver through the birth canal. Please don’t get caught up in worrying about how your baby is positioned and which direction they face as you enter labor. Throughout your labor, you and your baby are working together. As you work through contractions, your baby will make the transitions and movements needed for birth. There are specific labor positions that are evidence-based to allow more room in your pelvis to make it easier for your baby to come out. Some positions can even shorten your time in labor. See this episode for more information on the pros and cons of particular labor positions and what the research says about the best positions for labor and birth.

Interventions to Change Your Baby’s Position It can be a fun exercise to try and determine how your baby is positioned in your belly. While ideally wanting your baby’s head down, remember that only 3-4% of babies are breech at birth. You can use many interventions to try and coax your baby into the ideal position. The next episode of the Pregnancy Podcast will examine the efficacy of procedures to turn a breech baby into a head-down position. That episode will dive into the evidence on optimal fetal positioning, spinning babies, acupuncture, and an external cephalic version.

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