What is floating head in pregnancy?

A floating head in pregnancy refers to when the fetal head is not firmly engaged in the mother’s pelvis late in pregnancy. This occurs when the fetus is in a vertical position and the head is ‘floating’ above the pelvic inlet. A floating head is considered abnormal, as typically by 37 weeks gestation the baby’s head should be engaged in preparation for birth.

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What causes a floating head in late pregnancy?

There are a few potential causes of a floating fetal head late in pregnancy:

Breech presentation – If the baby is in a breech position (buttocks or feet down rather than head down), the head will not engage in the pelvis.
Premature labor – Engagement typically happens closer to full term. In premature labor, the head may not have engaged yet.
Pelvic abnormalities – Issues with the shape/size of the mother’s pelvis may prevent the head from properly engaging.

Placental position – If the placenta is low in the uterus, it may block the baby from settling into the pelvis.
Too much amniotic fluid – An excess volume (polyhydramnios) may prevent engagement.
Multiple pregnancy – The additional babies in a multiple pregnancy crowd the uterus and inhibit engagement.

Poor fetal positioning – If the baby is persistently in an oblique or transverse lie, the head cannot engage.

How is a floating head diagnosed?

A floating fetal head is typically diagnosed during a physical exam late in pregnancy. The provider will palpate the woman’s abdomen feeling specifically for the fetal head. If the head seems high up and ballottable (movable), this indicates it is not well applied to the cervix/pelvic inlet. An ultrasound may also be done to confirm the baby’s position and presentation.

Is a floating head concerning?

A floating fetal head can be concerning for a few reasons:

Increased risk of malpresentation – If the head is not engaged well in the pelvis, the baby is more likely to get into an abnormal position for delivery like breech or transverse lie.
Cesarean delivery – Poor engagement decreases the chances of successful vaginal delivery. Floating head often leads to C-section.
Cord prolapse – With rupture of membranes, an unengaged head puts the umbilical cord at risk of descending and being compressed.

Labor dysfunction – Lack of head engagement can cause stalled labor and failure to progress.
Preterm delivery – Floating head may indicate the start of preterm labor before the head has engaged.

What is the treatment for an unengaged head?

Treatment will depend on the cause and gestational age:

Breech presentation – Attempt external cephalic version to turn the baby head down. If unsuccessful, plan a C-section.
Premature labor – Give corticosteroids if before 34 weeks. Tocolytics may be used to try to stop labor.
Pelvic abnormalities – Counsel on high chance of C-section. Vaginal delivery may still be possible.

Placental position – Monitor placental location. May resolve on its own or need C-section.
Polyhydramnios – Remove excess fluid through amnioreduction procedures.
Multiple pregnancy – No intervention needed. Plan for C-section if engagement still poor by term.

Poor positioning – Try techniques to encourage baby into a head-down position like posture changes or chiropractic care.

If close to term with a floating head, induction or C-section may be recommended. Ongoing monitoring for umbilical cord prolapse is important.

What happens if the head is not engaged at term?

If a baby’s head is still floating and not engaged by 37-40 weeks gestation, the chance of spontaneous engagement decreases. At term with a floating head:

Labor induction may be offered to stimulate contractions to promote engagement.
Planning an elective C-section is reasonable due to the risk of emergency C-section for failure to progress in labor.
Vaginal delivery may still be possible but higher chance of complications like cord prolapse.

Fetal monitoring in labor is important to watch for signs of cord compression.
Forceps or vacuum delivery is less likely to be successful with an unengaged head.

Some providers may choose to wait and monitor if there are no other issues and the mother prefers to avoid intervention. However, at term or past the due date with a floating head, delivery is recommended.

Can you prevent a floating head?

There are a few things that may help promote head engagement in late pregnancy:

Maintaining good posture – Sitting and standing tall encourages fetal head descent.
Pelvic rocking – Rocking hips back and forth can help the head settle into the pelvis.

Birth ball exercises – Sitting on a birth ball and doing hip circles can encourage engagement.
Chiropractic care – Alignment of the pelvis may create more room for the head to engage.
Acupuncture – Some research suggests acupuncture can promote fetal positioning and engagement.

However, if there is an underlying cause like breech position or pelvic abnormality, engagement may still not occur. Preventing a floating head is not always possible.

What are the risks of an unengaged head?

Some risks associated with poor engagement of the fetal head include:

Cesarean delivery – Lack of engagement is associated with an increased risk of C-section for failure to progress in labor or suspected cephalopelvic disproportion.

Malpresentation – A floating head increases chances the baby flips into an abnormal position like breech or oblique lie.
Cord prolapse – With ruptured membranes, the unengaged head leaves more room for the cord to descend and be compressed.
Labor dysfunction – An unengaged head can lead to abnormal labor contractions and stalled labor.

Forceps failure – Attempted forceps delivery is often unsuccessful with a floating, unengaged head.

Monitoring fetal heart rate for signs of cord compression and planning early delivery can help minimize risks to the baby.

Key points about floating head in pregnancy

Floating head refers to when the fetal head is not engaged in the pelvis late in pregnancy.

Potential causes include breech position, premature labor, pelvic issues, placental position, polyhydramnios, multiples, and poor fetal positioning.
Risks include abnormal fetal positioning, C-section delivery, cord prolapse, and labor dysfunction.
Treatment depends on the cause but may include version, induction, cesarean delivery, amnioreduction, or positional techniques.

If not engaged by term, labor induction or C-section is typically recommended.
Preventive measures like posture, exercises, chiropractic care may help but are not always effective.

A floating fetal head is considered abnormal and concerning. Engagement in the pelvis is an important precursor to vaginal delivery. Lack of engagement may warrant interventions like induction or cesarean delivery to reduce risks to mother and baby.

Conclusion

A floating fetal head that is not engaged in the pelvis late in pregnancy can pose risks like malpresentation, cord prolapse, and obstructed labor. While some cases resolve spontaneously, an unengaged head often leads to induction of labor or cesarean delivery, especially if still floating at term. Preventive measures can be attempted but are not always successful if there is an underlying cause preventing engagement. Close monitoring and planning early delivery are key to improving outcomes with a floating fetal head.