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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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What Is Cephalic Position?

The ideal fetal position for labor and delivery

• Why It's Best

Risks of Other Positions

• Determining Position
• Turning a Fetus

The cephalic position is when a fetus is head down when it is ready to enter the birth canal. This is one of a few variations of how a fetus can rest in the womb and is considered the ideal one for labor and delivery.

About 96% of babies are born in the cephalic position. Most settle into it between the 32nd and 36th weeks of pregnancy . Your healthcare provider will monitor the fetus's position during the last weeks of gestation to ensure this has happened by week 36.

If the fetus is not in the cephalic position at that point, the provider may try to turn it. If this doesn't work, some—but not all—practitioners will attempt to deliver vaginally, while others will recommend a Cesarean (C-section).

Getty Images

Why Is the Cephalic Position Best?

During labor, contractions dilate the cervix so the fetus has adequate room to come through the birth canal. The cephalic position is the easiest and safest way for the baby to pass through the birth canal.

If the fetus is in a noncephalic position, delivery becomes more challenging. Different fetal positions have a range of difficulties and varying risks.

A small percentage of babies present in noncephalic positions. This can pose risks both to the fetus and the mother, and make labor and delivery more challenging. It can also influence the way in which someone can deliver.

A fetus may actually find itself in any of these positions throughout pregnancy, as the move about the uterus. But as they grow, there will be less room to tumble around and they will settle into a final position.

It is at this point that noncephalic positions can pose significant risks.

Cephalic Posterior

A fetus may also present in an occiput or cephalic posterior position. This means they are positioned head down, but they are facing the abdomen instead of the back.

This position is also nicknamed "sunny-side up."

Presenting this way increases the chance of a painful and prolonged delivery.

There are three different types of breech fetal positioning:

• Frank breech: The legs are up with the feet near the head.
• Footling breech: One or both legs is lowered over the cervix.
• Complete breech: The fetus is bottom-first with knees bent.

A vaginal delivery is most times a safe way to deliver. But with breech positions, a vaginal delivery can be complicated.

When a baby is born in the breech position, the largest part—its head—is delivered last. This can result in them getting stuck in the birth canal (entrapped). This can cause injury or death.

The umbilical cord may also be damaged or slide down into the mouth of the womb, which can reduce or cut off the baby's oxygen supply.

Some providers are still comfortable performing a vaginal birth as long as the fetus is doing well. But breech is always a riskier delivery position compared with the cephalic position, and most cases require a C-section.

Likelihood of a Breech Baby

You are more likely to have a breech baby if you:

• Go into early labor before you're full term
• Have an abnormally shaped uterus, fibroids , or too much amniotic fluid
• Are pregnant with multiples
• Have placenta previa (when the placenta covers the cervix)

Transverse Lie

In transverse lie position, the fetus is presenting sideways across the uterus rather than vertically. They may be:

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

If a transverse lie is not corrected before labor, a C-section will be required. This is typically the case.

Determining Fetal Position

Your healthcare provider can determine if your baby is in cephalic presentation by performing a physical exam and ultrasound.

In the final weeks of pregnancy, your healthcare provider will feel your lower abdomen with their hands to assess the positioning of the baby. This includes where the head, back, and buttocks lie

If your healthcare provider senses that the fetus is in a breech position, they can use ultrasound to confirm their suspicion.

Turning a Fetus So They Are in Cephalic Position

External cephalic version (ECV) is a common, noninvasive procedure to turn a breech baby into cephalic position while it's still in the uterus.

This is only considered if a healthcare provider monitors presentation progress in the last trimester and notices that a fetus is maintaining a noncephalic position as your delivery date approaches.

External Cephalic Version (ECV)

ECV involves the healthcare provider applying pressure to your stomach to turn the fetus from the outside. They will attempt to rotate the head forward or backward and lift the buttocks in an upward position. Sometimes, they use ultrasound to help guide the process.

The best time to perform ECV is about 37 weeks of pregnancy. Afterward, the fetal heart rate will be monitored to make sure it’s within normal levels. You should be able to go home after having ECV done.

ECV has a 50% to 60% success rate. However, even if it does work, there is still a chance the fetus will return to the breech position before birth.

Natural Methods For Turning a Fetus

There are also natural methods that can help turn a fetus into cephalic position. There is no medical research that confirms their efficacy, however.

• Changing your position: Sometimes a fetus will move when you get into certain positions. Two specific movements that your provider may recommend include: Getting on your hands and knees and gently rocking back and forth. Another you could try is pushing your hips up in the air while laying on your back with your knees bent and feet flat on the floor (bridge pose).
• Playing stimulating sounds: Fetuses gravitate to sound. You may be successful at luring a fetus out of breech position by playing music or a recording of your voice near your lower abdomen.
• Chiropractic care: A chiropractor can try the Webster technique. This is a specific chiropractic analysis and adjustment which enables chiropractors to establish balance in the pregnant person's pelvis and reduce undue stress to the uterus and supporting ligaments.
• Acupuncture: This is a considerably safe way someone can try to turn a fetus. Some practitioners incorporate moxibustion—the burning of dried mugwort on certain areas of the body—because they believe it will enhance the chances of success.

A Word From Verywell

While most babies are born in cephalic position at delivery, this is not always the case. And while some fetuses can be turned, others may be more stubborn.

This may affect your labor and delivery wishes. Try to remember that having a healthy baby, and staying well yourself, are your ultimate priorities. That may mean diverting from your best laid plans.

Speaking to your healthcare provider about turning options and the safest route of delivery may help you adjust to this twist and feel better about how you will move ahead.

Glezerman M. Planned vaginal breech delivery: current status and the need to reconsider . Expert Rev Obstet Gynecol. 2012;7(2):159-166. doi:10.1586/eog.12.2

Cleveland Clinic. Fetal positions for birth .

MedlinePlus. Breech birth .

UT Southwestern Medical Center. Can you turn a breech baby around?

The American College of Obstetricians and Gynecologists. If your baby is breech .

Roecker CB. Breech repositioning unresponsive to Webster technique: coexistence of oligohydramnios .  Journal of Chiropractic Medicine . 2013;12(2):74-78. doi:10.1016/j.jcm.2013.06.003

By Cherie Berkley, MS Berkley is a journalist with a certification in global health from Johns Hopkins University and a master's degree in journalism.

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CHAPTER 22:  Normal Labor

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Fetal orientation.

• MECHANISMS OF LABOR
• NORMAL LABOR CHARACTERISTICS
• MANAGEMENT OF NORMAL LABOR
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Labor is the process that leads to childbirth. It begins with the onset of regular uterine contractions and ends with delivery of the newborn and expulsion of the placenta. Pregnancy and birth are physiological processes. Thus, labor and delivery should be considered normal for most women.

Fetal position within the birth canal is critical to labor progress and to the delivery route. It should be determined in early labor, and sonography can be implemented for unclear cases. Important relationships include fetal lie, presentation, attitude, and position.

Of these, fetal lie describes the relationship of the fetal long axis to that of the mother. In more than 99 percent of labors at term, the fetal lie is longitudinal . A transverse lie is less frequent. Occasionally, the fetal and maternal axes may cross at a 45-degree angle to form an oblique lie . This is unstable and becomes longitudinal or transverse during labor.

Fetal Presentation

The presenting part is the portion of the fetal body either within or in closest proximity to the birth canal. It usually can be felt through the cervix on vaginal examination. In longitudinal lies, the presenting part is either the fetal head or the breech, creating cephalic and breech presentations, respectively. When the fetus lies with the long axis transversely, the shoulder is considered the presenting part.

Cephalic presentations are subclassified according to the relationship between the head and body of the fetus ( Fig. 22-1 ). Ordinarily, the head is flexed sharply so that the chin contacts the thorax. The occipital fontanel is the presenting part, and this presentation is referred to as a vertex or occiput presentation . Much less often, the fetal neck may be sharply extended so that the occiput and back come into contact, and the face is foremost in the birth canal— face presentation . The fetal head may assume a position between these extremes. When the neck is only partly flexed, the anterior (large) fontanel may present— sinciput presentation . When the neck is only partially extended, the brow may emerge— brow presentation . These latter two are usually transient. As labor progresses, sinciput and brow presentations almost always convert into occiput or face presentations by neck flexion or extension, respectively. If not, dystocia can develop ( Chap. 23 , p. 441).

FIGURE 22-1

Longitudinal lie, cephalic presentation. Differences in attitude of the fetal body in (A) occiput, (B) sinciput, (C) brow, and (D) face presentations. Note changes in fetal attitude as the fetal head becomes less flexed.

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Leopold maneuvers.

Shervonne S. Superville ; Marco A. Siccardi .

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Last Update: February 19, 2023 .

• Continuing Education Activity

The Leopold maneuvers are used to palpate the gravid uterus systematically. This method of abdominal palpation is of low cost, easy to perform, and non-invasive. It is used to determine the position, presentation, and engagement of the fetus in utero. This activity describes the four Leopold maneuvers and explains the method of systematic abdominal palpation used to assess fetal presentation and position in the third trimester of pregnancy.

• Describe the normal fetal presentation and position.
• Explain the four Leopold maneuvers.
• Summarize the clinical significance of abdominal palpation in the obstetric examination.
• Identify the importance of improving training in abdominal palpation to enhance the delivery of care for obstetric patients.
• Introduction

The Leopold maneuvers, named after the German obstetrician and gynecologist Christian Gerhard Leopold (1846–1911), are part of the physical examination of pregnant women. [1] [2] Four classical maneuvers are used to palpate the gravid uterus systematically. This method of abdominal palpation is of low cost, easy to perform, and non-invasive. It is used to determine the position, presentation, and engagement of the fetus in utero.

Fetal presentation refers to the fetal anatomic part proceeding first into the pelvic inlet. When the fetal head is approaching the pelvic inlet, it is referred to as a cephalic presentation. The commonest presentation is the vertex of the fetal head. Malpositions are abnormal positions of the vertex of the fetal head, using the occiput as the reference point, relative to the maternal pelvis. Malpresentations are all presentations of the fetus other than vertex, which includes the breech presentation, transverse and oblique lie. Spontaneous vaginal delivery is most common when a cephalic-presenting fetus is in the occiput anterior position. [3]

Malpresentation is estimated to occur in 5% of all deliveries and is an essential cause of the high cesarean delivery rate. [4]  It is essential to detect non-cephalic presentations before the onset of labor to mitigate the maternal and neonatal risks associated with complicated vaginal delivery or cesarean section. Detection of malpresentation in late pregnancy allows for counseling on adequate care measures. The underutilized external cephalic version and intrapartum planning and consenting are choices that can be discussed. [5] [6] [7]

Accurate assessment of fetal presentation and position is crucial in guiding obstetric management. However, the accuracy of Leopold maneuvers varies depending on many factors, especially examiner experience. Therefore ultrasonographic examination remains the current gold standard investigation for ensuring the fetus is in the cephalic presentation during the third trimester of pregnancy. It is recommended for confirmation when any malpresentation is even slightly suspected. [8] [9]

• Indications

Palpation is the contact of the operator's fingers and hands with the body of the woman or child. It offers the possibility of collecting data on an area, structure, or function by touch. Uterine contractions, the size of the pregnant uterus, any uterine masses, and attitude, presentation, degree of commitment of the fetus, and any fetal-pelvic disproportions can be detected.

Abdominal palpation is accurate in identifying the presentation, mainly if performed by experienced healthcare professionals. If in doubt about the presentation part, obstetric ultrasound should be used to confirm the results of the palpation. Ultrasound can also rule out fetal abnormalities, low placenta, hyperextension of the baby's head, and the presence of the umbilical cord around the neck of the fetus. The palpation technique requires skill and delicacy. The entire palm and fingers are useful for detecting myometrial activity, fetal movements, or any neoformations (fibroids), or the degree of edema. Palpation can be superficial or deep (the superficial one must always precede the deep one since the latter can cause pain); avoid having long nails because they can cause discomfort or injury.

From a psychological point of view, palpation is to be considered a form of analog communication between the midwife and the woman. Therefore through this technique, the operator can transmit the feelings they have towards the patient.

• Contraindications

While the benefits of abdominal palpation are challenging to quantify, the risks have not been identified. Evaluation of presentation by abdominal palpation before 36 weeks is not always accurate. Routine evaluation of the presentation with abdominal palpation should not be offered before 36 weeks, due to any inaccuracies and inconvenience to the woman. The fetal presentation should be evaluated with the abdominal palpation at 36 weeks or later when the presentation can affect plans for childbirth.

Leopold maneuvers are complicated maneuvers to perform on obese women and women who have polyhydramnios. Palpation can sometimes be uncomfortable for the patient if no precautions are taken to ensure that she is well-positioned and relaxed.

• Preparation

The aim of Leopold maneuvers is to determine the fetal presentation and position by systematically palpating the gravid abdomen. The initial steps are described below:  

• Explain the steps of the examination to the patient as this reduces anxiety and enhances cooperation
• Obtain consent
• The patient should be advised to void as an empty bladder promotes comfort and allows for more productive examination, and the distended bladder can obscure fetal contour
• Provision of privacy
• Prepare the equipment, such as measuring tape, Pinard stethoscope or Doppler transducer, and ultrasound gel
• Position the patient supine with the head of the bed raised to 15 degrees, and a small pillow or rolled towel placed on her right side
• Adequate exposure of the gravid abdomen from the xiphisternum to the pubic symphysis
• Inspect the gravid abdomen
• Technique or Treatment

The First Maneuver

The first maneuver also called the fundal grip, assesses the uterine fundus to determine its height and which fetal pole—that is, cephalic or podalic—occupies the fundus. The uterine contour is outlined by the examiner, placing both of his or her hands on each upper quadrant of the patient's abdomen facing the maternal xiphoid cartilage. The ulnar border of each hand is in contact with the abdominal wall, and the opposite fingers are touching each other. Using the fingertips, the fundus is gently palpated to identify which fetal part is present in the upper pole (fundus) of the uterus. The breach gives the sensation of a large, nodular mass, and its surface is uneven, non-ballotable, and not very mobile whereas the head feels hard and round with a smooth surface of uniform consistency, is very mobile and ballotable.

The first maneuver aims to determine the gestational age and the fetal lie.

Gestational age can be evaluated using fundal height or McDonald's rule. [1]  The uterine fundus reaches:

• The public symphysis at the 12th week
• A point midway between the pubic symphysis and the transverse and the transverse umbilical plane at the 16th week
• The transverse umbilical plane at the 20th week
• Having crossed this line, it is assumed each transverse finger breath corresponds to two weeks

The Second Maneuver

The second maneuver, sometimes called the umbilical grip, involves palpation of the lateral uterine surfaces. Still facing the maternal xiphoid cartilage, both hands slide down from the uterine fundus towards the lateral uterine walls. The clinician's hands are placed flat and parallel to each other along the abdominal wall at the level of the umbilicus. It allows establishing if the fetus is in a longitudinal, transverse, or oblique situation, and to determine the position of the back and small parts.The operator places the two flat hands sideways to the uterus and tries to bring them closer to the midline. In the approach maneuvers, the operator's hands are one on the back of the fetus and one on the small parts, which give different tactile sensations.The approach is possible when the fetus is in a longitudinal position regardless of the type of presentation, while it is not possible when the situation is transverse or oblique. Furthermore, it is possible to understand from which side the fetal back is located.

If the identification of the fetal back proves to be difficult, the provider can perform the following maneuvers. A simple adjustment involves alternating two hand palpation of lateral uterine surfaces. By placing the right hand steady on one side of the abdomen while using the palm of the left hand, the right side of the gravid uterus is palpated gently. This is then repeated using the opposite side. Otherwise, the Budin maneuver, named after French obstetrician and gynecologist Pierre-Constant Budin 1846–1907, can be performed for the precise determination of the position of the fetal back. [2] The uterine fundus is pressed with force using one hand, which accentuates the curvature of the fetal back, allowing for easier palpation with the other hand. The fetal heart can be auscultated at this time, which can also provide information on fetal orientation. The heart is well perceived when the stethoscope or the doppler transducer is placed on the back of the fetus.

The Third Maneuver

The third maneuver was modified by Karel Pawlík (1849–1914), a Czech gynecologist and obstetrician, and is referred to as the Pawlik grips. This maneuver aids in the confirmation of fetal presentation.

The first Pawlík grip, sometimes called the first pelvic grip, helps to define which presenting part of the fetus is situated in hypogastrium. Using the thumb and fingers of the right hand close above the pubic symphysis, the presenting part is grasped at the lower portion of the abdomen and draws the thumb and finger near to clasp the lower uterine segment including its contents.

In the second Pawlík grip, the clinician carries on by sliding the hand upward to determine the cervical groove: if the mass moves, the presenting part is not engaged. Then lateral movements and ballottement are performed. The differentiation between head and breech is made as in the first maneuver. This maneuver also allows for an assessment of the fetal weight and the volume of amniotic fluid.

The Fourth Maneuver

This fourth maneuver resembles the first maneuver; however, the examiner faces towards the maternal pelvis. This maneuver involves the examiner placing the palms of both hands on either side of the lower abdomen, with the tips of the fingers facing downward toward the pelvic inlet. The fingertips of each hand are used to apply deep pressure from the outside to the inside and in a craniocaudal direction along the lower contour of the uterus towards the birth canal. It is possible to identify the characteristics of the part presented and confirm the findings detected with the third Leopold maneuver. The fingers of both hands move gently along the sides of the uterus towards the pubis. The side where there is resistance to the descent of the fingers towards the pubis is larger is where the forehead is located. If the head of the fetus is well flexed, it should be on the opposite side from the back of the fetus. If the head of the fetus is extended, however, the occiput is perceived and is on the same side of the spine. It is possible to evaluate the degree of descent of the presented part and to realize if there are gross disproportions between this and the pelvic inlet.

This maneuver identifies which presenting part is in the lower uterine pole. To perceive how much of the cephalic extremity, which we recognized to be at the lower pole, descends into the birth canal: if it is entirely external, then it has not confronted itself, if it is confronting itself or if it has ultimately descended. The fingers travel the upper contour of the cephalic end, around the neck of the fetus.

Completing the fourth maneuver with the so-called "fifth maneuver" of Leopold, or maneuver of Zagenmeister, also can allow the approximate distance between the presenting part and the maternal pelvis. In the cephalic presentation, the hand is placed flat on the pubic symphysis, and the palpation could delineate the fetal head portion that can be reached above the pelvic inlet. Using the rule of fifths, the distance between the base and vertex of the fetal head is divided into five equal parts. Each fifth corresponding to 2 cm or approximately one transverse fingerbreadth. If the fetal head accommodates two fingerbreadths above the pelvic brim, it is said to be engaged.

• Complications

A breech presentation occurs when the presenting part is either the buttocks and/or the feet. On examination, the head is felt in the upper uterine pole and the breech in the pelvic cavity. The fetal heart tones are auscultated higher than anticipated with a vertex presentation.

When the longest axis of the fetus is oriented transversely, the presenting part is typically the shoulder. In the transverse lie on palpation, neither the head nor the buttocks can be palpated in the lower uterine pole inlet, and the fetal head can be felt in the flank.

Occiput posterior position occurs when the fetal occiput is at or posterior to the sacroiliac joint. On examination, there is a lower abdomen flattened, fetal limbs are palpable anteriorly, and the fetal heart tones may be auscultated in the flank.

Brow presentation occurs with some extension of the fetal head. On palpation, the fetal occiput is higher than the sinciput, and more than half the fetal head is felt above the symphysis pubis.

Face presentation results from hyperextension of the fetal head.  On palpation, the fold of the neck is felt as a deep indentation between the occiput and the back; however, in face presentation, this depression is limited.

• Clinical Significance

Few studies have compared the gold standard ultrasonography with clinical examination to detect non-cephalic presentation in the third trimester of pregnancy. These investigators found that abdominal palpation fails to detect a significant percentage of mal-presenting fetuses. [3]  

Clinical examination was relatively sensitive in multiparous women and those with lower body mass indices. The specificity of clinical examination increased significantly as gestational age increased, and body mass index decreased. When abdominal palpation was evaluated as a screening tool for identifying malpresentation, it was found that false-positive diagnoses were a more frequent error because of the low prevalence of malpresentation in low-risk populations. [4]

Leopold maneuvers have been reported to be difficult in obese pregnant women and pregnancies complicated with polyhydramnios, fibroids, or anterior placental location. In clinical practice, the use of repeated procedures by a second examiner, pelvic examination, and rescheduling a return visit with a sequential abdominal examination can serve to improve the accuracy of abdominal palpation findings.

Leopold maneuvers can help mothers to perceive and visualize fetuses. Thus abdominal palpations can develop the maternal-fetal relationship, which plays an important role in a child's psychological, cognitive, and social development. [5] [6] [7]

• Enhancing Healthcare Team Outcomes

All healthcare providers should be competent with the methods to perform abdominal palpation of a gravid uterus and the significance of the findings. The findings observed should be documented and can be used to guide further obstetric management. Identifying pregnancies complicated by malpresentation and referral to appropriate facilities may lead to improved outcomes for both neonate and mother. [8]

Offering an external cephalic version (ECV) for breech presentation can contribute to the safe lowering of the primary cesarean delivery rate. [9]  Training for existing or new staff who are moving to midwifery-obstetric care is necessary as experienced clinicians can be effective in using abdominal palpation as a screening tool for fetal malpresentation, particularly in settings where ultrasound may not be readily available. [4]

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Leopold Maneuvers (A) , First Maneuver (B) Second Maneuver (C) Third Maneuver (D) Fourth Maneuver Illustrated by Junior Maloney

Disclosure: Shervonne Superville declares no relevant financial relationships with ineligible companies.

Disclosure: Marco Siccardi declares no relevant financial relationships with ineligible companies.

This book is distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International (CC BY-NC-ND 4.0) ( http://creativecommons.org/licenses/by-nc-nd/4.0/ ), which permits others to distribute the work, provided that the article is not altered or used commercially. You are not required to obtain permission to distribute this article, provided that you credit the author and journal.

• Cite this Page Superville SS, Siccardi MA. Leopold Maneuvers. [Updated 2023 Feb 19]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-.

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• Stages of Labor. [StatPearls. 2024] Stages of Labor. Hutchison J, Mahdy H, Hutchison J. StatPearls. 2024 Jan
• Sonographic diagnosis of fetal head deflexion and the risk of cesarean delivery. [Am J Obstet Gynecol MFM. 2020] Sonographic diagnosis of fetal head deflexion and the risk of cesarean delivery. Bellussi F, Livi A, Cataneo I, Salsi G, Lenzi J, Pilu G. Am J Obstet Gynecol MFM. 2020 Nov; 2(4):100217. Epub 2020 Aug 18.
• Value of routine ultrasound examination at 35-37 weeks' gestation in diagnosis of non-cephalic presentation. [Ultrasound Obstet Gynecol. 2020] Value of routine ultrasound examination at 35-37 weeks' gestation in diagnosis of non-cephalic presentation. De Castro H, Ciobanu A, Formuso C, Akolekar R, Nicolaides KH. Ultrasound Obstet Gynecol. 2020 Feb; 55(2):248-256.
• Review Intrapartum ultrasound for the diagnosis of cephalic malpositions and malpresentations. [Am J Obstet Gynecol MFM. 2021] Review Intrapartum ultrasound for the diagnosis of cephalic malpositions and malpresentations. Gimovsky AC. Am J Obstet Gynecol MFM. 2021 Nov; 3(6S):100438. Epub 2021 Jul 22.
• Review Sonographic evaluation of the fetal head position and attitude during labor. [Am J Obstet Gynecol. 2022] Review Sonographic evaluation of the fetal head position and attitude during labor. Ghi T, Dall'Asta A. Am J Obstet Gynecol. 2022 Jul 6; . Epub 2022 Jul 6.

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What Are Leopold's Maneuvers?

Ariel Skelley / Getty Images

• What Are Leopold's Maneuvers?
• How Are Leopold's Maneuvers Performed?

Why Are They Performed?

Fetal weight estimate, risks and contraindications.

Leopold's maneuvers are a non-invasive way to estimate your baby's position and size in utero. The four maneuvers are the fundal grip, the umbilical grip, Pawlik's grip, and the pelvic grip. These maneuvers are performed in late pregnancy by trained healthcare providers who palpate (examine by touch) the pregnant person's abdomen to determine the baby's size and placement in the uterus.

"This process allows medical professionals to not only make a birth weight estimate but also address any underlying problems that may occur down the road," explains Mackenzie Schutz , RN. Knowing if the baby is head down is important at the end of pregnancy in order to plan for a safe delivery.

These maneuvers get their name from the influential 19th-century German obstetrician and gynecologist Christian Gerhard Leopold, who discussed and propagated their use among other physicians. They may also be called Leopold maneuvers. Learn more about Leopold's maneuvers, including why, when, and how they are performed during pregnancy.

How Are Leopold's Maneuvers Performed?

There are four distinct maneuvers, each with a different technique.

• Fundal grip : A healthcare provider palpates the upper abdomen with both hands to feel for the fetus's head, trunk, and bottom in order to get an idea of its size and position.
• Pawlik's grip : A provider uses their fingers and thumb to feel what part of the fetus is in the lower abdomen, just above the birth canal, to see if they're in the right position. This maneuver assesses fetal weight and amniotic fluid volume.
• Pelvic grip : A provider moves their fingers towards the pelvis, then slides their hands over the side of the uterus to determine where the fetus's brow is located.
• Umbilical grip : A provider applies deep pressure with the palm of one hand while using the other hand to feel the uterus. This allows them to identify the location of the fetus's back and small parts.

Leopold's maneuvers should only be performed by qualified medical professionals who have received training on how to perform them safely. You shouldn't attempt to do them yourself.

"Leopold maneuvers a wonderful way to determine quickly how the fetus is lying in a person's uterus," explains Kecia Gaither , OB/GYN, doctor of maternal-fetal medicine, and director of perinatal services at NYC Health and Hospitals/Lincoln. "And, in experienced hands, they can give an estimate of fetal weight."

They're also low-cost, non-invasive, and don't require the use of expensive equipment such as an ultrasound . Plus they tell your provider how ready your baby is for birth so they can better prepare for your labor.

Ideal Position

At the beginning of your pregnancy, your fetus will move around your womb freely, but towards the end, they should get into a position that's optimal for vaginal delivery. Before birth, your baby should be head-down, facing your back, with their chin tucked to their chest so that their head is ready to enter the pelvis. This is called the cephalic presentation and it is the ideal position for childbirth.

Most babies will settle into this position between the 32nd and 36th week of pregnancy. This position makes labor less complicated. Around 96% of babies will be born in the cephalic position.

Cephalic Posterior Position

This position is also known as an occiput position or it's sometimes nicknamed "sunny-side-up." It means that your baby is positioned head down, but they're facing out instead of towards your spine. This position could increase your chances of a painful and prolonged delivery.

Breech Position

A breech position means that your baby's bottom is facing downwards. There are three different breech positions:

• Frank breech: The baby's legs are up, with feet near the head
• Footling breech: One or both legs are lowered in the cervix
• Complete breech: The baby's bottom is first and its knees are bent

Any of these positions can make for a riskier delivery, so you are at risk of a C-section delivery if the baby doesn't change position before labor.

Transverse Lie

Your baby might also be in a transverse lie position at the end of the third trimester, which means they are lying sideways across your uterus instead of vertically. If they don't change position, it could make for dangerous labor, so a C-section will be required.

Leopold's maneuvers can also be used to estimate how big your baby is. Fetal weight estimates help your healthcare provider plan for birth, too. In general, a baby who is estimated to be 10 pounds or more might require a C-section birth because your baby could get caught in the birth canal.

There are no known risks for using Leopold's maneuvers, as long as they are being performed by qualified medical professionals. However, they are as accurate at determining the position or estimated weight of your baby before the 36th week of your pregnancy. So, your medical provider will not likely use them before your 36-week checkup.

For your own comfort, your provider will likely ask you to pee before they do the procedure, because a full bladder can make it difficult to really determine your baby's position with accuracy.

Your provider might also not use these maneuvers if you were in an accident. "If blunt force trauma has occurred during pregnancy, it may be best to use an ultrasound to avoid any further bruising that could be worsened by palpating," explains Shutz.

Leopold's maneuvers are typically very accurate, but it is possible that your healthcare provider will still perform an ultrasound prior to your delivery to confirm your baby's position, particularly if they are concerned that your baby has moved or is in a transverse or breech position.

Leopold's maneuvers are difficult to perform on people who are obese because it is difficult to feel the baby's position.

They are also more complicated to perform on patients who have polyhydramnios , which is when you have too much amniotic fluid surrounding your baby, as well as people with fibroids.

A Word From Verywell

Leopold's maneuvers are usually performed after 36 weeks by your healthcare provider to determine your baby's position and estimate their birth weight. This will help you and your provider be better prepared for your labor and determine if it might be safer to perform a c-section. The maneuvers should not hurt and they are very accurate, though your provider might still perform an ultrasound to confirm any findings.

Superville SS, Siccardi MA. Leopold maneuvers. In:  StatPearls [Internet]. StatPearls Publishing.

American College of Obstetricians and Gynecologists. If your baby is breech .

Kachlík D, Kästner I, Baca V. Christian Gerhard Leopold: Fascinating history of a productive obstetrician gynecologist . Obstet Gynecol Surv. 2012;67(1):1-5. doi:10.1097/OGX.0b013e31823662d7

Tell N, Omuso I, Hunter K, Khandelwal M. Accuracy of Leopold's maneuver compared to ultrasound in estimating fetal birth weight . Obstet Gynecol. 2019;133(1):23S-24S. doi:10.1097/01.AOG.0000559397.09291.a3

Glezerman M.  Planned vaginal breech delivery: current status and the need to reconsider . Expert Rev Obstet Gynecol . 2012;7(2):159-166. doi:10.1586/eog.12.2

Cleveland Clinic.  Fetal positions for birth .

Wei Y, Yang H.  [Variation of prevalence of macrosomia and cesarean section and its influencing factors] .  Zhonghua Fu Chan Ke Za Zhi.  2015;50(3):170-6. doi:10.3760/cma.j.issn.0529-567x.2015.03.002

Superville SS, Siccardi MA. Leopold maneuvers . In:  StatPearls . StatPearls Publishing.

By Simone Scully Simone is the health editorial director for performance marketing at Verywell. She has over a decade of experience as a professional journalist covering pregnancy, parenting, health, medicine, science, and lifestyle topics.

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

• Key Points |

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 transverse 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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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?

What to know if your baby is breech

What's a sunny-side up baby?

What happens to your baby right after birth

How your twins’ fetal positions affect labor and delivery

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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INTRODUCTION

PATHOGENESIS AND RISK FACTORS

● The fetus does not fully occupy the pelvis, thus allowing a fetal extremity room to prolapse. Predisposing factors include early gestational age, multiple gestation, polyhydramnios, or a large maternal pelvis relative to fetal size [ 2,3 ].

● Membrane rupture occurs when the presenting part is still high, which allows flow of amniotic fluid to carry a fetal extremity, umbilical cord, or both toward the birth canal.

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Your baby in the birth canal

During labor and delivery, your baby must pass through your pelvic bones to reach the vaginal opening. The goal is to find the easiest way out. Certain body positions give the baby a smaller shape, which makes it easier for your baby to get through this tight passage.

The best position for the baby to pass through the pelvis is with the head down and the body facing toward the mother's back. This position is called occiput anterior.

Information

Certain terms are used to describe your baby's position and movement through the birth canal.

FETAL STATION

Fetal station refers to where the presenting part is in your pelvis.

• The presenting part. The presenting part is the part of the baby that leads the way through the birth canal. Most often, it is the baby's head, but it can be a shoulder, the buttocks, or the feet.
• Ischial spines. These are bone points on the mother's pelvis. Normally the ischial spines are the narrowest part of the pelvis.
• 0 station. This is when the baby's head is even with the ischial spines. The baby is said to be "engaged" when the largest part of the head has entered the pelvis.
• If the presenting part lies above the ischial spines, the station is reported as a negative number from -1 to -5.

In first-time moms, the baby's head may engage by 36 weeks into the pregnancy. However, engagement may happen later in the pregnancy, or even during labor.

This refers to how the baby's spine lines up with the mother's spine. Your baby's spine is between their head and tailbone.

Your baby will most often settle into a position in the pelvis before labor begins.

• If your baby's spine runs in the same direction (parallel) as your spine, the baby is said to be in a longitudinal lie. Nearly all babies are in a longitudinal lie.
• If the baby is sideways (at a 90-degree angle to your spine), the baby is said to be in a transverse lie.

FETAL ATTITUDE

The fetal attitude describes the position of the parts of your baby's body.

The normal fetal attitude is commonly called the fetal position.

• The head is tucked down to the chest.
• The arms and legs are drawn in towards the center of the chest.

Abnormal fetal attitudes include a head that is tilted back, so the brow or the face presents first. Other body parts may be positioned behind the back. When this happens, the presenting part will be larger as it passes through the pelvis. This makes delivery more difficult.

DELIVERY PRESENTATION

Delivery presentation describes the way the baby is positioned to come down the birth canal for delivery.

The best position for your baby inside your uterus at the time of delivery is head down. This is called cephalic presentation.

• This position makes it easier and safer for your baby to pass through the birth canal. Cephalic presentation occurs in about 97% of deliveries.
• There are different types of cephalic presentation, which depend on the position of the baby's limbs and head (fetal attitude).

If your baby is in any position other than head down, your doctor may recommend a cesarean delivery.

Breech presentation is when the baby's bottom is down. Breech presentation occurs about 3% of the time. There are a few types of breech:

• A complete breech is when the buttocks present first and both the hips and knees are flexed.
• A frank breech is when the hips are flexed so the legs are straight and completely drawn up toward the chest.
• Other breech positions occur when either the feet or knees present first.

The shoulder, arm, or trunk may present first if the fetus is in a transverse lie. This type of presentation occurs less than 1% of the time. Transverse lie is more common when you deliver before your due date, or have twins or triplets.

CARDINAL MOVEMENTS OF LABOR

As your baby passes through the birth canal, the baby's head will change positions. These changes are needed for your baby to fit and move through your pelvis. These movements of your baby's head are called cardinal movements of labor.

• This is when the widest part of your baby's head has entered the pelvis.
• Engagement tells your health care provider that your pelvis is large enough to allow the baby's head to move down (descend).
• This is when your baby's head moves down (descends) further through your pelvis.
• Most often, descent occurs during labor, either as the cervix dilates or after you begin pushing.
• During descent, the baby's head is flexed down so that the chin touches the chest.
• With the chin tucked, it is easier for the baby's head to pass through the pelvis.

Internal Rotation

• As your baby's head descends further, the head will most often rotate so the back of the head is just below your pubic bone. This helps the head fit the shape of your pelvis.
• Usually, the baby will be face down toward your spine.
• Sometimes, the baby will rotate so it faces up toward the pubic bone.
• As your baby's head rotates, extends, or flexes during labor, the body will stay in position with one shoulder down toward your spine and one shoulder up toward your belly.
• As your baby reaches the opening of the vagina, usually the back of the head is in contact with your pubic bone.
• At this point, the birth canal curves upward, and the baby's head must extend back. It rotates under and around the pubic bone.

External Rotation

• As the baby's head is delivered, it will rotate a quarter turn to be in line with the body.
• After the head is delivered, the top shoulder is delivered under the pubic bone.
• After the shoulder, the rest of the body is usually delivered without a problem.

Alternative Names

Shoulder presentation; Malpresentations; Breech birth; Cephalic presentation; Fetal lie; Fetal attitude; Fetal descent; Fetal station; Cardinal movements; Labor-birth canal; Delivery-birth canal

Barth WH. Malpresentations and malposition. In: Landon MB, Galan HL, Jauniaux ERM, et al, eds. Gabbe's Obstetrics: Normal and Problem Pregnancies . 8th ed. Philadelphia, PA: Elsevier; 2021:chap 17.

Kilpatrick SJ, Garrison E, Fairbrother E. Normal labor and delivery. In: Landon MB, Galan HL, Jauniaux ERM, et al, eds. Gabbe's Obstetrics: Normal and Problem Pregnancies . 8th ed. Philadelphia, PA: Elsevier; 2021:chap 11.

Review Date 11/10/2022

Updated by: John D. Jacobson, MD, Department of Obstetrics and Gynecology, Loma Linda University School of Medicine, Loma Linda, CA. Also reviewed by David C. Dugdale, MD, Medical Director, Brenda Conaway, Editorial Director, and the A.D.A.M. Editorial team.

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