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The way a baby is positioned in the uterus just before birth can have a big effect on labor and delivery. This positioning is called fetal presentation.

Babies twist, stretch and tumble quite a bit during pregnancy. Before labor starts, however, they usually come to rest in a way that allows them to be delivered through the birth canal headfirst. This position is called cephalic presentation. But there are other ways a baby may settle just before labor begins.

Following are some of the possible ways a baby may be positioned at the end of pregnancy.

Head down, face down

When a baby is head down, face down, the medical term for it is the cephalic occiput anterior position. This the most common position for a baby to be born in. With the face down and turned slightly to the side, the smallest part of the baby's head leads the way through the birth canal. It is the easiest way for a baby to be born.

Head down, face up

When a baby is head down, face up, the medical term for it is the cephalic occiput posterior position. In this position, it might be harder for a baby's head to go under the pubic bone during delivery. That can make labor take longer.

Most babies who begin labor in this position eventually turn to be face down. If that doesn't happen, and the second stage of labor is taking a long time, a member of the health care team may reach through the vagina to help the baby turn. This is called manual rotation.

In some cases, a baby can be born in the head-down, face-up position. Use of forceps or a vacuum device to help with delivery is more common when a baby is in this position than in the head-down, face-down position. In some cases, a C-section delivery may be needed.

Frank breech

When a baby's feet or buttocks are in place to come out first during birth, it's called a breech presentation. This happens in about 3% to 4% of babies close to the time of birth. The baby shown below is in a frank breech presentation. That's when the knees aren't bent, and the feet are close to the baby's head. This is the most common type of breech presentation.

If you are more than 36 weeks into your pregnancy and your baby is in a frank breech presentation, your health care professional may try to move the baby into a head-down position. This is done using a procedure called external cephalic version. It involves one or two members of the health care team putting pressure on your belly with their hands to get the baby to roll into a head-down position.

If the procedure isn't successful, or if the baby moves back into a breech position, talk with a member of your health care team about the choices you have for delivery. Most babies in a frank breech position are born by planned C-section.

Complete and incomplete breech

A complete breech presentation, as shown below, is when the baby has both knees bent and both legs pulled close to the body. In an incomplete breech, one or both of the legs are not pulled close to the body, and one or both of the feet or knees are below the baby's buttocks. If a baby is in either of these positions, you might feel kicking in the lower part of your belly.

If you are more than 36 weeks into your pregnancy and your baby is in a complete or incomplete breech presentation, your health care professional may try to move the baby into a head-down position. This is done using a procedure called external cephalic version. It involves one or two members of the health care team putting pressure on your belly with their hands to get the baby to roll into a head-down position.

If the procedure isn't successful, or if the baby moves back into a breech position, talk with a member of your health care team about the choices you have for delivery. Many babies in a complete or incomplete breech position are born by planned C-section.

When a baby is sideways — lying horizontal across the uterus, rather than vertical — it's called a transverse lie. In this position, the baby's back might be:

• Down, with the back facing the birth canal.
• Sideways, with one shoulder pointing toward the birth canal.
• Up, with the hands and feet facing the birth canal.

Although many babies are sideways early in pregnancy, few stay this way when labor begins.

If your baby is in a transverse lie during week 37 of your pregnancy, your health care professional may try to move the baby into a head-down position. This is done using a procedure called external cephalic version. External cephalic version involves one or two members of your health care team putting pressure on your belly with their hands to get the baby to roll into a head-down position.

If the procedure isn't successful, or if the baby moves back into a transverse lie, talk with a member of your health care team about the choices you have for delivery. Many babies who are in a transverse lie are born by C-section.

If you're pregnant with twins and only the twin that's lower in the uterus is head down, as shown below, your health care provider may first deliver that baby vaginally.

Then, in some cases, your health care team may suggest delivering the second twin in the breech position. Or they may try to move the second twin into a head-down position. This is done using a procedure called external cephalic version. External cephalic version involves one or two members of the health care team putting pressure on your belly with their hands to get the baby to roll into a head-down position.

Your health care team may suggest delivery by C-section for the second twin if:

• An attempt to deliver the baby in the breech position is not successful.
• You do not want to try to have the baby delivered vaginally in the breech position.
• An attempt to move the baby into a head-down position is not successful.
• You do not want to try to move the baby to a head-down position.

In some cases, your health care team may advise that you have both twins delivered by C-section. That might happen if the lower twin is not head down, the second twin has low or high birth weight as compared to the first twin, or if preterm labor starts.

• Landon MB, et al., eds. Normal labor and delivery. In: Gabbe's Obstetrics: Normal and Problem Pregnancies. 8th ed. Elsevier; 2021. https://www.clinicalkey.com. Accessed May 19, 2023.
• Holcroft Argani C, et al. Occiput posterior position. https://www.updtodate.com/contents/search. Accessed May 19, 2023.
• Frequently asked questions: If your baby is breech. American College of Obstetricians and Gynecologists https://www.acog.org/womens-health/faqs/if-your-baby-is-breech. Accessed May 22, 2023.
• Hofmeyr GJ. Overview of breech presentation. https://www.updtodate.com/contents/search. Accessed May 22, 2023.
• Strauss RA, et al. Transverse fetal lie. https://www.updtodate.com/contents/search. Accessed May 22, 2023.
• Chasen ST, et al. Twin pregnancy: Labor and delivery. https://www.updtodate.com/contents/search. Accessed May 22, 2023.
• Cohen R, et al. Is vaginal delivery of a breech second twin safe? A comparison between delivery of vertex and non-vertex second twins. The Journal of Maternal-Fetal & Neonatal Medicine. 2021; doi:10.1080/14767058.2021.2005569.
• Marnach ML (expert opinion). Mayo Clinic. May 31, 2023.

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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?

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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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Cephalic Position: Getting Baby in the Right Position for Birth

You know your busy bean is exploring their digs because sometimes you can feel those little feet kick you in the ribs (ouch!) to help propel them along. Just think of them as a little astronaut attached to you — the mother ship — with their oxygen (umbilical) cord.

Your baby may start moving around before you’re barely 14 weeks pregnant. However, you probably won’t feel anything until about the 20 th week of pregnancy.

If your baby is bouncing around or turning in your womb, it’s a good sign. A moving baby is a healthy baby. There are even cute names for when you first feel your baby moving, like “fluttering” and “quickening.” Your baby’s movement is most important in the third trimester .

By this time, your growing baby may not be moving that much because the womb isn’t as roomy as it used to be. But your baby can probably still do acrobatic flips and turn himself upside down. Your doctor will closely monitor where your baby’s head is as your due date nears.

Your baby’s position inside you can make all the difference in how you give birth. Most babies automatically get into the head-first cephalic position just before they are born.

What is cephalic position?

If you’re getting closer to your exciting due date, you might have heard your doctor or midwife mention the term cephalic position or cephalic presentation. This is the medical way of saying that baby is bottom and feet up with their head down near the exit, or birth canal.

It’s difficult to know which way is up when you’re floating in a warm bubble, but most babies (up to 96 percent) are ready to go in the head-first position before birth. The safest delivery for you and your baby is for them to squeeze through the birth canal and into the world headfirst.

Your doctor will start checking your baby’s position at week 34 to 36 of your pregnancy. If your baby is not head down by week 36, your doctor might try to gently nudge them into position.

Keep in mind, though, that positions can continue to change, and your baby’s position really doesn’t come into play until you’re ready to deliver.

There are two kinds of cephalic (head-down) positions that your little one might assume:

• Cephalic occiput anterior . Your baby is head down and facing your back. Almost 95 percent of babies in the head-first position face this way. This position is considered to be the best for delivery because its easiest for the head to “crown” or come out smoothly as you give birth.
• Cephalic occiput posterior . Your baby is head down with their face turned toward your belly. This can make delivery a bit harder because the head is wider this way and more likely to get stuck. Only about 5 percent of cephalic babies face this way. This position is sometimes called a “ sunny side up baby .”

Some babies in the head-first cephalic position might even have their heads tilted back so they move through the birth canal and enter the world face first. But this is very rare and most common in preterm (early) deliveries.

What are the other positions?

Your baby might settle into a breech (bottom-down) position or even a transverse (sideways) position.

A breech baby can cause complications for both mom and baby. This is because the birth canal has to open wider if your baby decides to come out bottom first. It’s also easier for their legs or arms to get tangled up a bit as they slide out. However, only about four percent of babies are in the bottom-first position when it’s time for delivery.

There are also different kinds of breech positions your baby could be in:

• Frank breech. This is when your baby’s bottom is down and their legs are straight up (like a pretzel) so their feet are close to their face. Babies are definitely flexible!
• Complete breech . This is when your baby is settled into an almost legs crossed position with their bottom down.
• Incomplete breech . If one of your baby’s legs are bent (like sitting cross-legged) while the other one is trying to kick toward their head or another direction, they’re in an incomplete breech position.
• Footling breech . Just like it sounds, this is one when or both of baby’s feet are down in the birth canal so they would exit foot first.

A sideways position where your baby is lying horizontally across your stomach is also called a transverse lie. Some babies start like this close to your due date but then decide to shift all the way into the head-first cephalic position.

So if your baby is settled across your stomach like they’re swinging in a hammock, they may just be tired and taking a break from all the moving before another shift.

In rare cases, a baby can get wedged sideways in the womb (and not because the poor thing didn’t try moving). In these cases, your doctor might recommend a cesarean section (C-section) for your delivery.

How do you know what position your baby is in?

Your doctor can find out exactly where your baby is by:

• A physical exam: feeling and pressing over your belly to get an outline of your baby
• An ultrasound scan: provides an exact image of your baby and even which way they’re facing
• Listening to your baby’s heartbeat: honing in on the heart gives your doctor a good estimate of where your baby is settled inside your womb

If you’re already in labor and your baby is not turning into a cephalic presentation — or suddenly decides to acrobat into a different position — your doctor might be concerned about your delivery.

Other things that your doctor has to check include where the placenta and umbilical cord are inside your womb. A moving baby can sometimes get their foot or hand caught in their umbilical cord. Your doctor might have to decide on the spot whether a C-section is better for you and your baby.

How can you tell your baby’s position?

You might be able to tell what position your baby is in by where you feel their little feet practice their soccer kick. If your baby is in a breech (bottom-first) position, you might feel kicking in your lower stomach or groin area. If your baby is in the cephalic (head-down) position, they might score a goal in your ribs or upper stomach.

If you rub your belly, you might be able to feel your baby well enough to figure out what position they’re in. A long smooth area is likely your little one’s back, a round hard area is their head, while bumpy parts are legs and arms. Other curved areas are probably a shoulder, hand, or foot. You might even see the impression of a heel or hand against the inside of your belly!

What is lightening?

Your baby will likely naturally drop into a cephalic (head-down) position sometime between weeks 37 to 40 of your pregnancy. This strategic positional change by your brilliant little one is called “lightening.” You might feel a heavy or full sense in your lower stomach — that’s baby’s head!

You might also notice that your belly button is now more of an “outie” than an “innie.” That’s also your baby’s head and upper body pushing against your stomach.

As your baby gets into cephalic position, you might suddenly notice that you can breathe more deeply because they’re not pushing up any longer. However, you might have to pee even more often because your baby is pushing against your bladder.

Can your baby be turned?

Stroking your belly helps you feel your baby, and your baby feels you right back. Sometimes stroking or tapping your stomach over the baby will get them to move . There are also some at-home methods for turning a baby, like inversions or yoga positions.

Doctors use a technique called external cephalic version (ECV) to get a breech baby into cephalic position. This involves massaging and pushing on your belly to help nudge your baby in the right direction. In some cases, medications that help you and your muscles relax can help turn your baby.

If your baby is already in cephalic position but not quite facing the right way, a doctor can sometimes reach through the vagina during labor to help gently turn baby the other way.

Of course, turning a baby also depends on how large they are — and how petite you are. And if you’re pregnant with multiples, your babies can be changing positions even during birth as the space in your womb opens up.

About 95 percent of babies drop down into the head-first position a few weeks or days before their due date. This is called the cephalic position, and it’s safest for mom and baby when it comes to giving birth.

There are different kinds of cephalic positions. The most common and safest one is where baby is facing your back. If your little one decides to change positions or refuses to float head down in your womb, your doctor might be able to coax him into the cephalic position.

Other baby positions like breech (bottom first) and transverse (sideways) might mean that you must have a C-section delivery. Your doctor will help you decide what’s best for you and your little one when it’s time for delivery.

• 3rd Trimester

How we reviewed this article:

• BirthPlace. (n.d.) https://www.stmarysregional.com/services/women/birthplace
• Glezerman M. (2014). Planned vaginal breech delivery: Current status and the need to reconsider. DOI: https://doi.org/10.1586/eog.12.2
• Horsager-Boehrer R. (2015). Feeling your baby move during pregnancy. https://utswmed.org/medblog/fetal-movements/
• Mayo Clinic Staff. (2017). Fetal presentation before birth. https://www.mayoclinic.org/healthy-lifestyle/pregnancy-week-by-week/multimedia/fetal-positions/sls-20076615
• Your baby’s movement and position. (2019). https://wa.kaiserpermanente.org/healthAndWellness/index.jhtml?item=%2Fcommon%2FhealthAndWellness%2Fpregnancy%2Fpregnancy%2FthirdMove.html

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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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Abnormal Fetal lie, Malpresentation and Malposition

Original Author(s): Anna Mcclune Last updated: 1st December 2018 Revisions: 12

• 1 Definitions
• 2 Risk Factors
• 3.2 Presentation
• 3.3 Position
• 4 Investigations
• 5.1 Abnormal Fetal Lie
• 5.2 Malpresentation
• 5.3 Malposition

The lie, presentation and position of a fetus are important during labour and delivery.

In this article, we will look at the risk factors, examination and management of abnormal fetal lie, malpresentation and malposition.

Definitions

• Longitudinal, transverse or oblique
• Cephalic vertex presentation is the most common and is considered the safest
• Other presentations include breech, shoulder, face and brow
• Usually the fetal head engages in the occipito-anterior position (the fetal occiput facing anteriorly) – this is ideal for birth
• Other positions include occipito-posterior and occipito-transverse.

Note: Breech presentation is the most common malpresentation, and is covered in detail here .

Fig 1 – The two most common fetal presentations: cephalic and breech.

Risk Factors

The risk factors for abnormal fetal lie, malpresentation and malposition include:

• Multiple pregnancy
• Uterine abnormalities (e.g fibroids, partial septate uterus)
• Fetal abnormalities
• Placenta praevia
• Primiparity

Identifying Fetal Lie, Presentation and Position

The fetal lie and presentation can usually be identified via abdominal examination. The fetal position is ascertained by vaginal examination.

For more information on the obstetric examination, see here .

• Face the patient’s head
• Place your hands on either side of the uterus and gently apply pressure; one side will feel fuller and firmer – this is the back, and fetal limbs may feel ‘knobbly’ on the opposite side

Presentation

• Palpate the lower uterus (above the symphysis pubis) with the fingers of both hands; the head feels hard and round (cephalic) and the bottom feels soft and triangular (breech)
• You may be able to gently push the fetal head from side to side

The fetal lie and presentation may not be possible to identify if the mother has a high BMI, if she has not emptied her bladder, if the fetus is small or if there is polyhydramnios .

During labour, vaginal examination is used to assess the position of the fetal head (in a cephalic vertex presentation). The landmarks of the fetal head, including the anterior and posterior fontanelles, indicate the position.

Fig 2 – Assessing fetal lie and presentation.

Investigations

Any suspected abnormal fetal lie or malpresentation should be confirmed by an ultrasound scan . This could also demonstrate predisposing uterine or fetal abnormalities.

Abnormal Fetal Lie

If the fetal lie is abnormal, an external cephalic version (ECV) can be attempted – ideally between 36 and 38 weeks gestation.

ECV is the manipulation of the fetus to a cephalic presentation through the maternal abdomen.

It has an approximate success rate of 50% in primiparous women and 60% in multiparous women. Only 8% of breech presentations will spontaneously revert to cephalic in primiparous women over 36 weeks gestation.

Complications of ECV are rare but include fetal distress , premature rupture of membranes, antepartum haemorrhage (APH) and placental abruption. The risk of an emergency caesarean section (C-section) within 24 hours is around 1 in 200.

ECV is contraindicated in women with a recent APH, ruptured membranes, uterine abnormalities or a previous C-section .

Fig 3 – External cephalic version.

Malpresentation

The management of malpresentation is dependent on the presentation.

• Breech – attempt ECV before labour, vaginal breech delivery or C-section
• Brow – a C-section is necessary
• If the chin is anterior (mento-anterior) a normal labour is possible; however, it is likely to be prolonged and there is an increased risk of a C-section being required
• If the chin is posterior (mento-posterior) then a C-section is necessary
• Shoulder – a C-section is necessary

Malposition

90% of malpositions spontaneously rotate to occipito-anterior as labour progresses. If the fetal head does not rotate, rotation and operative vaginal delivery can be attempted. Alternatively a C-section can be performed.

• Usually the fetal head engages in the occipito-anterior position (the fetal occiput facing anteriorly) - this is ideal for birth

If the fetal lie is abnormal, an external cephalic version (ECV) can be attempted - ideally between 36 and 38 weeks gestation.

• Breech - attempt ECV before labour, vaginal breech delivery or C-section

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Presentation and position of baby through pregnancy and at birth

9-minute read

If you are concerned about your baby’s movements, contact your doctor or midwife for advice immediately.

• If you baby is in a breech presentation, your doctor may recommend trying a technique called an external cephalic version to try and move your baby while they are still in the uterus for an easier birth.

What does presentation and position mean?

Presentation refers to the part of your baby’s body that is facing downwards in the direction of the birth canal.

Position refers to where your baby’s occiput (the bottom part of the back of their head) is in relation to your body.

If your baby is in a breech presentation , then position refers to where your baby’s sacrum (lower back) is in relation to your body.

People — including medical professionals — sometimes use these terms incorrectly. Sometimes when speaking about babies in breech presentation, the word ‘position’ will be used to refer to their presentation. For example, you may read information or hear people say ‘breech position’ instead of ‘breech presentation’.

What are the different types of presentation my baby could be in during pregnancy and birth?

Most babies present headfirst, also known as cephalic presentation. Most babies that are headfirst will be vertex presentation. This means that the crown of their head sits at the opening of your birth canal.

In rare cases, your baby can be headfirst but in face or brow presentation, which may not be suitable for vaginal birth.

If your baby is in a breech presentation, their feet or bottom will be closest to your birth canal. The 3 most common types of breech presentation are:

• frank or extended breech — where your baby’s legs are straight up in front of their body, with their feet up near their face
• complete or flexed breech — where your baby is in a sitting position with their legs crossed in front of their body and their feet near their bottom
• footling breech — where one or both of your baby’s feet are hanging below their bottom, so the foot or feet are coming first

Read more on breech presentation .

What are the different positions my baby could be in during pregnancy and birth?

If your baby is headfirst, the 3 main types of presentation are:

• anterior – when the back of your baby’s head is at the front of your belly
• lateral – when the back of your baby’s head is facing your side
• posterior – when the back of your baby’s head is towards your back

How will I know what presentation and position my baby is in?

Your doctor or midwife can usually work out your baby’s presentation by feeling your abdomen. They may also double check it with a portable ultrasound. Your baby’s presentation is usually checked around 36 weeks .

Your doctor or midwife will also confirm your baby’s head position in labour by examining your belly and using an ultrasound , and they may also do a vaginal examination . During the vaginal examination they are feeling for certain ridges on your baby’s head called sutures and fontanelles that help them work out which way your baby is positioned.

What is the ideal presentation and position for baby to be in for a vaginal birth?

For a vaginal birth, your baby will ideally be headfirst with the back of their head at the front of your belly, also known as being in the anterior position. This position is best for labour and birth since it means that the smallest part of your baby’s head goes down the birth canal first.

When does a baby usually get in the ideal presentation and position for birth?

Your baby will usually be in a headfirst position by 37 weeks of pregnancy. Around 3 in every 100 babies will be in breech presentation after 37 weeks.

Your baby’s position can change with your contractions during labour as they move down the birth canal, so their exact position can change during labour.

What are my options if baby isn't in the ideal presentation or position for a vaginal birth?

If your baby is in a breech presentation, your doctor may recommend a technique called an external cephalic version (ECV) to try and move your baby while they are still in the uterus . An ECV involves your doctor using their hands to apply pressure on your belly and help turn your baby to a headfirst position. It has a 1 in 2 chance of success and is a safe option in most pregnancies.

There is no evidence to show that alternative therapies, such as exercises, acupuncture or chiropractic treatments, help your baby change from a breech presentation to headfirst.

If your baby remains breech, your doctor may discuss having a breech vaginal birth. Not all doctors and hospitals offer this option. They may also suggest you birth your baby with a planned caesarean section .

If your baby’s presentation is headfirst but the position of your baby’s head is not ideal for labour, it can lead to a longer labour, and potential complications . The position of your baby’s head will often change as your labour progresses. If it doesn’t, sometimes you can still give birth without assistance, or you may need your doctor to help turn your baby’s head or help your birth with a vacuum or forceps .

Any procedure or decision for a type of birth will only go ahead with your consent . You will be able to discuss all the options with your doctor, and based on your preferences for yourself and your baby’s safety, make a decision together .

Resources and support

The Royal Australian and New Zealand College of Obstetrics and Gynaecology has a factsheet about the options available to you if your baby is in a breech presentation at the end of your pregnancy .

Mercy Perinatal has information on external cephalic version (ECV) safety and benefits if your baby is in a breech presentation at the end of your pregnancy.

The Women’s Hospital has information about the different presentations and positions your baby could be in, and how it can affect your birthing experience.

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Last reviewed: October 2023

Related pages

External cephalic version (ecv), malpresentation, breech pregnancy, search our site for.

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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

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

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

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

Malpresentation is when your baby is in an unusual position as the birth approaches. Sometimes it’s possible to move the baby, but a caesarean maybe safer.

Labour complications

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

ECV is a procedure to try to move your baby from a breech position to a head-down position. This is performed by a trained doctor.

Having a baby

The articles in this section relate to having a baby – what to consider before becoming pregnant, pregnancy and birth, and after your baby is born.

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Your pelvis helps to carry your growing baby and is tailored for vaginal births. Learn more about the structure and function of the female pelvis.

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Breech Births

In the last weeks of pregnancy, a baby usually moves so his or her head is positioned to come out of the vagina first during birth. This is called a vertex presentation. A breech presentation occurs when the baby’s buttocks, feet, or both are positioned to come out first during birth. This happens in 3–4% of full-term births.

What are the different types of breech birth presentations?

• Complete breech: Here, the buttocks are pointing downward with the legs folded at the knees and feet near the buttocks.
• Frank breech: In this position, the baby’s buttocks are aimed at the birth canal with its legs sticking straight up in front of his or her body and the feet near the head.
• Footling breech: In this position, one or both of the baby’s feet point downward and will deliver before the rest of the body.

What causes a breech presentation?

The causes of breech presentations are not fully understood. However, the data show that breech birth is more common when:

• You have been pregnant before
• In pregnancies of multiples
• When there is a history of premature delivery
• When the uterus has too much or too little amniotic fluid
• When there is an abnormally shaped uterus or a uterus with abnormal growths, such as fibroids
• The placenta covers all or part of the opening of the uterus placenta previa

How is a breech presentation diagnosed?

A few weeks prior to the due date, the health care provider will place her hands on the mother’s lower abdomen to locate the baby’s head, back, and buttocks. If it appears that the baby might be in a breech position, they can use ultrasound or pelvic exam to confirm the position. Special x-rays can also be used to determine the baby’s position and the size of the pelvis to determine if a vaginal delivery of a breech baby can be safely attempted.

Can a breech presentation mean something is wrong?

Even though most breech babies are born healthy, there is a slightly elevated risk for certain problems. Birth defects are slightly more common in breech babies and the defect might be the reason that the baby failed to move into the right position prior to delivery.

Can a breech presentation be changed?

It is preferable to try to turn a breech baby between the 32nd and 37th weeks of pregnancy . The methods of turning a baby will vary and the success rate for each method can also vary. It is best to discuss the options with the health care provider to see which method she recommends.

Medical Techniques

External Cephalic Version (EVC)  is a non-surgical technique to move the baby in the uterus. In this procedure, a medication is given to help relax the uterus. There might also be the use of an ultrasound to determine the position of the baby, the location of the placenta and the amount of amniotic fluid in the uterus.

Gentle pushing on the lower abdomen can turn the baby into the head-down position. Throughout the external version the baby’s heartbeat will be closely monitored so that if a problem develops, the health care provider will immediately stop the procedure. ECV usually is done near a delivery room so if a problem occurs, a cesarean delivery can be performed quickly. The external version has a high success rate and can be considered if you have had a previous cesarean delivery.

ECV will not be tried if:

• You are carrying more than one fetus
• There are concerns about the health of the fetus
• You have certain abnormalities of the reproductive system
• The placenta is in the wrong place
• The placenta has come away from the wall of the uterus ( placental abruption )

Complications of EVC include:

• Prelabor rupture of membranes
• Changes in the fetus’s heart rate
• Placental abruption
• Preterm labor

Vaginal delivery versus cesarean for breech birth?

Most health care providers do not believe in attempting a vaginal delivery for a breech position. However, some will delay making a final decision until the woman is in labor. The following conditions are considered necessary in order to attempt a vaginal birth:

• The baby is full-term and in the frank breech presentation
• The baby does not show signs of distress while its heart rate is closely monitored.
• The process of labor is smooth and steady with the cervix widening as the baby descends.
• The health care provider estimates that the baby is not too big or the mother’s pelvis too narrow for the baby to pass safely through the birth canal.
• Anesthesia is available and a cesarean delivery possible on short notice

What are the risks and complications of a vaginal delivery?

In a breech birth, the baby’s head is the last part of its body to emerge making it more difficult to ease it through the birth canal. Sometimes forceps are used to guide the baby’s head out of the birth canal. Another potential problem is cord prolapse . In this situation the umbilical cord is squeezed as the baby moves toward the birth canal, thus slowing the baby’s supply of oxygen and blood. In a vaginal breech delivery, electronic fetal monitoring will be used to monitor the baby’s heartbeat throughout the course of labor. Cesarean delivery may be an option if signs develop that the baby may be in distress.

When is a cesarean delivery used with a breech presentation?

Most health care providers recommend a cesarean delivery for all babies in a breech position, especially babies that are premature. Since premature babies are small and more fragile, and because the head of a premature baby is relatively larger in proportion to its body, the baby is unlikely to stretch the cervix as much as a full-term baby. This means that there might be less room for the head to emerge.

Want to Know More?

• Creating Your Birth Plan
• Labor & Birth Terms to Know
• Cesarean Birth After Care

Compiled using information from the following sources:

• ACOG: If Your Baby is Breech
• William’s Obstetrics Twenty-Second Ed. Cunningham, F. Gary, et al, Ch. 24.
• Danforth’s Obstetrics and Gynecology Ninth Ed. Scott, James R., et al, Ch. 21.

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

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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 vertex 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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• Labor & Delivery

What Causes Breech Presentation?

Learn more about the types, causes, and risks of breech presentation, along with how breech babies are typically delivered.

What Is Breech Presentation?

Types of breech presentation, what causes a breech baby, can you turn a breech baby, how are breech babies delivered.

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Toward the end of pregnancy, your baby will start to get into position for delivery, with their head pointed down toward the vagina. This is otherwise known as vertex presentation. However, some babies turn inside the womb so that their feet or buttocks are poised to be delivered first, which is commonly referred to as breech presentation, or a breech baby.

As you near the end of your pregnancy journey, an OB-GYN or health care provider will check your baby's positioning. You might find yourself wondering: What causes breech presentation? Are there risks involved? And how are breech babies delivered? We turned to experts and research to answer some of the most common questions surrounding breech presentation, along with what causes this positioning in the first place.

During your pregnancy, your baby constantly moves around the uterus. Indeed, most babies do somersaults up until the 36th week of pregnancy , when they pick their final position in the womb, says Laura Riley , MD, an OB-GYN in New York City. Approximately 3-4% of babies end up “upside-down” in breech presentation, with their feet or buttocks near the cervix.

Breech presentation is typically diagnosed during a visit to an OB-GYN, midwife, or health care provider. Your physician can feel the position of your baby's head through your abdominal wall—or they can conduct a vaginal exam if your cervix is open. A suspected breech presentation should ultimately be confirmed via an ultrasound, after which you and your provider would have a discussion about delivery options, potential issues, and risks.

There are three types of breech babies: frank, footling, and complete. Learn about the differences between these breech presentations.

Frank Breech

With frank breech presentation, your baby’s bottom faces the cervix and their legs are straight up. This is the most common type of breech presentation.

Footling Breech

Like its name suggests, a footling breech is when one (single footling) or both (double footling) of the baby's feet are in the birth canal, where they’re positioned to be delivered first .

Complete Breech

In a complete breech presentation, baby’s bottom faces the cervix. Their legs are bent at the knees, and their feet are near their bottom. A complete breech is the least common type of breech presentation.

Other Types of Mal Presentations

The baby can also be in a transverse position, meaning that they're sideways in the uterus. Another type is called oblique presentation, which means they're pointing toward one of the pregnant person’s hips.

Typically, your baby's positioning is determined by the fetus itself and the shape of your uterus. Because you can't can’t control either of these factors, breech presentation typically isn’t considered preventable. And while the cause often isn't known, there are certain risk factors that may increase your risk of a breech baby, including the following:

• The fetus may have abnormalities involving the muscular or central nervous system
• The uterus may have abnormal growths or fibroids
• There might be insufficient amniotic fluid in the uterus (too much or too little)
• This isn’t your first pregnancy
• You have a history of premature delivery
• You have placenta previa (the placenta partially or fully covers the cervix)
• You’re pregnant with multiples
• You’ve had a previous breech baby

In some cases, your health care provider may attempt to help turn a baby in breech presentation through a procedure known as external cephalic version (ECV). This is when a health care professional applies gentle pressure on your lower abdomen to try and coax your baby into a head-down position. During the entire procedure, the fetus's health will be monitored, and an ECV is often performed near a delivery room, in the event of any potential issues or complications.

However, it's important to note that ECVs aren't for everyone. If you're carrying multiples, there's health concerns about you or the baby, or you've experienced certain complications with your placenta or based on placental location, a health care provider will not attempt an ECV.

The majority of breech babies are born through C-sections . These are usually scheduled between 38 and 39 weeks of pregnancy, before labor can begin naturally. However, with a health care provider experienced in delivering breech babies vaginally, a natural delivery might be a safe option for some people. In fact, a 2017 study showed similar complication and success rates with vaginal and C-section deliveries of breech babies.

That said, there are certain known risks and complications that can arise with an attempt to deliver a breech baby vaginally, many of which relate to problems with the umbilical cord. If you and your medical team decide on a vaginal delivery, your baby will be monitored closely for any potential signs of distress.

Ultimately, it's important to know that most breech babies are born healthy. Your provider will consider your specific medical condition and the position of your baby to determine which type of delivery will be the safest option for a healthy and successful birth.

ACOG. If Your Baby Is Breech .

American Pregnancy Association. Breech Presentation .

Gray CJ, Shanahan MM. Breech Presentation . [Updated 2022 Nov 6]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-.

Mount Sinai. Breech Babies .

Takeda J, Ishikawa G, Takeda S. Clinical Tips of Cesarean Section in Case of Breech, Transverse Presentation, and Incarcerated Uterus . Surg J (N Y). 2020 Mar 18;6(Suppl 2):S81-S91. doi: 10.1055/s-0040-1702985. PMID: 32760790; PMCID: PMC7396468.

Shanahan MM, Gray CJ. External Cephalic Version . [Updated 2022 Nov 6]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. 

Fonseca A, Silva R, Rato I, Neves AR, Peixoto C, Ferraz Z, Ramalho I, Carocha A, Félix N, Valdoleiros S, Galvão A, Gonçalves D, Curado J, Palma MJ, Antunes IL, Clode N, Graça LM. Breech Presentation: Vaginal Versus Cesarean Delivery, Which Intervention Leads to the Best Outcomes? Acta Med Port. 2017 Jun 30;30(6):479-484. doi: 10.20344/amp.7920. Epub 2017 Jun 30. PMID: 28898615.

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KS3 pregnancy foetus foetal development

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New-Onset Rheumatoid Arthritis in Pregnancy: A Case Report

1 Obstetrics and Gynecology, Mardan Medical Complex, Mardan, PAK

Muzamil Khan

2 Internal Medicine, The George Washington University School of Medicine and Health Sciences, Washington DC, USA

Satkarjeet Kaur Gill

3 Internal Medicine, Jagare Ridge Medical Clinic, Edmonton, CAN

Rizwanullah

4 Internal Medicine, Hayatabad Medical Complex, Peshawar, PAK

Karthiga Vasudevan

5 Preventive Medicine, Yerevan State Medical University, Yerevan, ARM

Kiya Gurmessa

6 Public Health, Johns Hopkins University, Baltimore, USA

Sophia Tahir

7 Internal Medicine, Windsor University School of Medicine, Cayon, KNA

Rheumatoid arthritis (RA) is extremely uncommon during pregnancy. The alterations in the immune system that occur to support the developing fetus make the onset of RA during this period unlikely. In this case report, we describe a 26-year-old pregnant woman who presented with bilateral symmetrical pain in her hands, wrists, and ankles at 24 weeks of gestation. After a thorough evaluation, she was diagnosed with active RA based on clinical symptoms and laboratory findings, including elevated inflammatory markers, positive RA factor, and anti-cyclic citrullinated peptide antibodies. Treatment was initiated with hydroxychloroquine (HCQ), prednisolone, and paracetamol, resulting in significant symptom improvement and no postpartum complications. The patient gave birth to a healthy baby via vaginal delivery, highlighting the management challenges and outcomes linked to RA during pregnancy.

Introduction

Rheumatoid arthritis (RA) is a chronic systemic autoimmune disorder that impacts women three times more often than men, typically during their most productive and childbearing years [ 1 ]. The progression of RA frequently alters during pregnancy, with around 50% of pregnant women experiencing low disease activity. Between 20% and 40% of these women achieve remission by the third trimester; however, nearly 20% will experience a worsening or moderate-to-high disease activity, necessitating additional therapeutic intervention [ 2 ].

The remission of RA during pregnancy can be linked to the shift from Th1-mediated immunity to Th2. This shift suppresses Th1 cells while enhancing Th2 cells, which promotes humoral and antibody-based immunity. RA is a chronic inflammatory condition mainly driven by immunological dysfunction and T-cell infiltration. These T cells release cytokines, causing inflammation and arthritis due to cartilage destruction and systemic symptoms. The primary characteristic of RA is inflammatory synovitis, usually affecting the peripheral joints [ 3 ].

The postpartum period is a time when women are especially susceptible to RA flares and the initial onset of RA. There is a higher incidence of RA following the first pregnancy, particularly within the first nine months. Up to 90% of patients with RA may experience postpartum flares, typically within the first three months, and these flares are more common after the first pregnancy [ 4 ].

Due to the immunological changes that occur during pregnancy, autoimmune diseases are rare during this period. There are only a few documented cases of RA in pregnant women. In this report, we present the case of a 26-year-old woman who, at 24 weeks of gestation, experienced bilateral symmetrical pain in her hands, wrists, and ankle joints. She was subsequently diagnosed with active RA.

Case presentation

A 26-year-old primigravida, who was 24 weeks pregnant, visited the outpatient department of Hayatabad Medical Complex in Peshawar. She had been experiencing bilateral symmetrical pain in her hands, wrists, and ankles for the past three months. She reported no previous comorbidities and no family history of autoimmune diseases. Upon further questioning, she mentioned experiencing morning stiffness in the affected joints for about 30 minutes, which improved with physical activity.

During the rheumatological examination, she exhibited tenderness in eight proximal interphalangeal joints, as well as in her wrist and ankle joints. Her range of motion was restricted due to pain. The rest of her abdominal, respiratory, neurological, cardiovascular, and dermatological examinations were unremarkable. 

Our differential diagnosis included RA, systemic lupus erythematosus, carpal tunnel syndrome, and hypothyroidism. Hypothyroidism was ruled out as the patient exhibited no significant features of this condition, and her thyroid profile was normal. Carpal tunnel syndrome was also excluded due to negative results for Tinel's Sign and Phalen's Test, along with normal nerve conduction studies (NCS) and electromyography (EMG) studies. She presented no clinical features of SLE other than rheumatological signs, and her ANA and dsDNA tests were negative. Although RA is rare during pregnancy, some cases have been reported. Considering this possibility, we investigated her for RA, which was confirmed by the positivity of rheumatoid factor (RF) and anti-CCP antibodies.

Laboratory investigations revealed leukocytosis, elevated inflammatory markers, and significantly positive RA and anti-cyclic citrullinated peptide antibodies (anti-CCP). Other tests, including anti-neutrophilic antibodies (ANA), extractable nuclear antigen (ENA), and anti-double-stranded DNA (anti-dDNA), were negative (Table ​ (Table1). 1 ). Her Disease Activity Score 28 (DAS 28) was calculated at 4.3, indicating moderate severity.

WBC, white blood cell count; mcL, microliter; mg/dL, milligram per deciliter; IU/mL, international units per milliliter; CRP, C-reactive protein; ESR, erythrocyte sedimentation rate; RF, rheumatoid factor; anti-CCP, anti-cyclic citrullinated peptide 

Considering this a case of active RA, she was started on oral hydroxychloroquine (HCQ) 400 mg per day, oral prednisolone 10 mg per day, and analgesic paracetamol. After a one-month follow-up, her clinical condition had improved, along with a reduction in inflammatory markers (Figure ​ (Figure1). 1 ). At 38 weeks of gestation, she had a normal vaginal delivery, with a baby weighing 3.5 kg. No anomalies were detected during the pediatric assessment.

ESR, erythrocyte sedimentation rate; CRP, C-reactive protein

The precise mechanism through which RA tends to improve during pregnancy remains incompletely understood. However, it is thought that pregnancy creates a condition of immune tolerance because of the presence of the semi-allogeneic fetus. This tolerance encompasses several immunological mechanisms, such as thymus regression, decreased natural killer cell function, and a shift in immune reaction from Th1 cells toward Th2 dominance [ 5 ]. Additionally, molecules expressed by the syncytiotrophoblast, such as decay-accelerating factor and membrane cofactor protein, inhibit complement activation, protecting embryonic cells from complement-mediated damage [ 6 ]. From a cellular immunity standpoint, the activation of T cells at the maternal-fetal interface is suppressed by the local production of indoleamine 2,3-dioxygenase, an enzyme that breaks down tryptophan-an amino acid crucial for T-cell activation [ 7 ]. There have been a total of five documented cases of RA occurring during pregnancy [ 8 - 11 ].

Non-steroidal anti-inflammatory drugs (NSAIDs) are generally considered safe for use during pregnancy; however, they are not recommended during the final trimester due to the potential risk of premature closure of the ductus arteriosus. If symptoms arise or worsen during pregnancy, NSAIDs are the preferred treatment option. Glucocorticoids, such as prednisone, are commonly prescribed when NSAIDs are not advisable. The aim is to administer prednisone at the lowest effective dose, usually not exceeding 10 mg daily, to manage the condition. Nonfluorinated glucocorticoids like prednisolone, prednisone, and methylprednisolone pass through the placenta in small amounts and are metabolized into inactive forms before reaching the fetus. Hence, they are generally regarded as safe for use during pregnancy at low to moderate doses [ 12 ].

Disease-modifying antirheumatic drugs (DMARDs) such as HCQ, sulfasalazine (SSZ), and azathioprine (AZA) can be continued for patients who do not respond adequately to NSAIDs or prednisone. For moderately active disease, HCQ and/or SSZ may be prescribed. Methotrexate (MTX) and leflunomide (LEF) should be avoided during pregnancy [ 13 ]. Biological treatments such as tumor necrosis factor (TNF) inhibitors may be maintained during pregnancy based on the particular medication and a careful assessment of the individual risks and benefits involved [ 14 ].

We initiated treatment for our patient with HCQ at a daily dose of 400 mg, oral prednisolone at 10 mg per day, and paracetamol for pain relief. After one month of monitoring, the patient experienced notable symptom improvement, with no complications or disease flare-ups postpartum. The baby was delivered vaginally without complications, weighed within normal limits, and showed no abnormalities.

While many women with RA often experience improvement during pregnancy, it is crucial not to overlook disease flares or mistake them for pregnancy-related symptoms. Patients presenting with both typical and atypical RA symptoms should undergo a thorough evaluation for various rheumatologic conditions to ensure accurate diagnosis and timely initiation of suitable treatment. The initial onset of RA during pregnancy could indicate a potentially more severe clinical trajectory. Further research focusing on this distinct patient population is essential to better understand the long-term prognosis of their condition.

Conclusions

This case report underscores the complexities of managing RA during pregnancy, where disease progression varies widely among individuals. Pregnancy-induced immunological changes often result in improved RA symptoms, influenced by shifts in immune responses and hormonal dynamics. However, some patients may experience disease flares or new-onset RA during pregnancy, necessitating vigilant monitoring and tailored therapeutic approaches. Our patient, diagnosed with active RA at 24 weeks of gestation, responded positively to treatment with HCQ, prednisolone, and paracetamol, achieving significant symptom relief and favorable postpartum outcomes. This highlights the critical role of early diagnosis and appropriate management in mitigating potential complications and ensuring the well-being of both mother and fetus. Further research is essential to better understand the underlying mechanisms of RA's behavior during pregnancy and optimize therapeutic strategies for pregnant women with RA.

Acknowledgments

All authors, representing various parts of the world, contributed per the International Committee of Medical Journal Editors (ICMJE) guidelines. We are a collective of researchers who regularly exchange ideas and collaborate on projects aligned with our specific areas of interest. Each author made significant contributions to the conception or design of the study or the acquisition, analysis, or interpretation of data. They were also involved in drafting the manuscript or critically revising it for essential intellectual content. Every author provided final approval of the version to be published and agreed to take responsibility for all aspects of the work, ensuring that any questions regarding the accuracy or integrity of any part of the work were properly addressed and resolved. We are committed to advancing the research component of our medical careers.

Disclosures

Human subjects: Consent was obtained or waived by all participants in this study.

Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following:

Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work.

Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work.

Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work.

Author Contributions

Concept and design:   . Rizwanullah, Aiysha Gul, Satkarjeet Kaur Gill, Karthiga Vasudevan, Kiya Gurmessa, Muzamil Khan, Sophia Tahir

Acquisition, analysis, or interpretation of data:   . Rizwanullah, Aiysha Gul, Satkarjeet Kaur Gill, Karthiga Vasudevan, Kiya Gurmessa, Muzamil Khan, Sophia Tahir

Drafting of the manuscript:   . Rizwanullah, Aiysha Gul, Satkarjeet Kaur Gill, Karthiga Vasudevan, Kiya Gurmessa, Muzamil Khan, Sophia Tahir

Critical review of the manuscript for important intellectual content:   . Rizwanullah, Aiysha Gul, Satkarjeet Kaur Gill, Karthiga Vasudevan, Kiya Gurmessa, Muzamil Khan, Sophia Tahir

Supervision:   . Rizwanullah, Aiysha Gul