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Occipital presentation of the fetus: high head erection
Medical expert of the article
Last reviewed: 07.07.2025
The position of the fetus, that is, the relation of its back to the wall of the uterus, is correct when the back is turned to the side. A profoundly incorrect position is when the back is turned straight forward or straight back. In these cases, complications are possible during labor, since the head with its largest size (straight) is inserted into the smallest size of the entrance to the small pelvis - into the straight size of the entrance, into the true conjugate.
Depending on where the back and back of the head are facing - forward to the symphysis or backward to the promontory - there are two types of high upright standing: anterior, positio occipitalis pubica s. anterior, and posterior, positio occipitalis sacralis s. posterior.
The bent back of the fetus is more easily reduced in front, in accordance with the protrusion of the uterine wall and abdominal wall, than in the back, where the mother's spine is protruded due to physiological lordosis. That is why the anterior view is more common than the posterior one. Characteristic of these insertion anomalies is the location of the sagittal suture in the direct size of the entrance to the pelvis. Thus, the high direct standing of the head is usually designated as its position, when it, being in a state of bending, stands at the entrance to the small pelvis with the sagittal suture in the direct size of the pelvis.
The causes of high erect standing of the head are varied. It occurs with different forms of the head and with various forms of the pelvis, both normal and flat, transversely narrowed, funnel-shaped, generally uniformly narrowed.
[ How to recognize a high erect head position?
Before the waters break, the high erect position of the head is often not diagnosed, and since it is rare, the possibility of its occurrence may simply be forgotten. However, even before the waters break, such a deviation can be suspected: an unusually narrow head hanging over the pubic symphysis is determined above the entrance to the small pelvis, which is moved by hand in the transverse direction. During labor, the sagittal suture remains erect throughout the birth canal, except for temporary deviations to the side. The period of expulsion is delayed, because a strong configuration of the skull is needed for successful expulsion.
Childbirth with a high, upright position of the head?
The outcome of childbirth with a high, upright position of the head depends on many factors: the nature of the birth forces, the correspondence between the mother's pelvis and the size of the fetal head, and the ability of the head to be configured.
With good labor activity, the head can shift, the sagittal suture is inserted into one of the oblique dimensions and labor ends according to the type of occipital insertions. If such a shift does not occur, the high direct position of the head turns into a high direct insertion and labor takes on a pronounced pathological character: contractions intensify, become sharply painful, prolonged.
The anterior type of high direct insertion of the head is more favorable in comparison with the posterior type, since it is more likely to result in spontaneous labor. However, it occurs in no more than half of the cases. The small head can pass through the entire birth canal without internal rotation. The first movement of the labor mechanism is flexion, with the suboccipital region resting against the symphysis, the area of the large fontanelle and the forehead passing along the promontory; then the second rotation occurs - extension, and the head rolls out from under the pubic symphysis. External rotation of the head is performed in the same way as with occipital insertions.
In a woman with a full-term pregnancy with an average size of the fetus, insertion of the head into the direct size of the pelvis is difficult, since there is a discrepancy between the size of the pelvis and the size of the fetus. The difficulty of the head's passage lies in the fact that the direct size of the entrance to the small pelvis is 11 cm, and the direct size of the head, with which it is inserted, is 12 cm, and the head in this size is little capable of configuration. Therefore, insurmountable obstacles often arise, secondary labor weakness develops, labor is delayed. Intrauterine asphyxia and death of the fetus occur.
Prolonged compression of the soft tissues of the birth canal by the head is accompanied by the formation of vesicovaginal fistulas, and without timely assistance, uterine rupture may occur. The duration of labor can range from 17 to 63 hours.
Particularly difficult is the birth with the posterior type of high direct insertion of the head. However, sooner or later the head may shift with the sagittal suture to the oblique size of the pelvis and the head descends into the small pelvis. Then the internal rotation of the head continues until its sagittal suture is established in the direct size of the exit, and the suboccipital fossa approaches the pubic symphysis.
If the shift of the sagittal suture does not occur, the situation of the mother and fetus becomes extremely dangerous and is aggravated by serious complications - infection, uterine rupture, etc.
It is important to recognize the high erect position of the head at the beginning of labor, when the fetus remains mobile, and to perform a cesarean section. It is advisable not to postpone the operation in order to avoid intrauterine fetal asphyxia. In case of prolonged labor complicated by weak labor and intrauterine fetal asphyxia, a cesarean section should be performed with great caution, since it is possible to extract a non-viable child with hemorrhages in the brain. In case of a dead fetus, a craniotomy should be performed.
In classical obstetrics, obstetric assistance was allowed in this situation - shifting the head like a Kegel ball or performing an external-internal rotation of the fetus on the leg with subsequent stretching of the fetus. To facilitate insertion of the head into the small pelvis, the mother is recommended to take the Walcher position for 20-30 minutes.
High direct insertion of the head is deservedly recognized by all obstetricians as a severe obstetric pathology. Spontaneous birth without obstetric assistance and operations is possible only in 13.1% of cases, with anterior type - 2 times more often than with posterior type.