face presentation presenting diameter

Face and Brow Presentation

• Author: Teresa Marino, MD; Chief Editor: Carl V Smith, MD  more...
• Sections Face and Brow Presentation
• Mechanism of Labor
• Labor Management

At the onset of labor, assessment of the fetal presentation with respect to the maternal birth canal is critical to the route of delivery. At term, the vast majority of fetuses present in the vertex presentation, where the fetal head is flexed so that the chin is in contact with the fetal thorax. The fetal spine typically lies along the longitudinal axis of the uterus. Nonvertex presentations (including breech, transverse lie, face, brow, and compound presentations) occur in less than 4% of fetuses at term. Malpresentation of the vertex presentation occurs if there is deflexion or extension of the fetal head leading to brow or face presentation, respectively.

In a face presentation, the fetal head and neck are hyperextended, causing the occiput to come in contact with the upper back of the fetus while lying in a longitudinal axis. The presenting portion of the fetus is the fetal face between the orbital ridges and the chin. The fetal chin (mentum) is the point designated for reference during an internal examination through the cervix. The occiput of a vertex is usually hard and has a smooth contour, while the face and brow tend to be more irregular and soft. Like the occiput, the mentum can present in any position relative to the maternal pelvis. For example, if the mentum presents in the left anterior quadrant of the maternal pelvis, it is designated as left mentum anterior (LMA).

In a brow presentation, the fetal head is midway between full flexion (vertex) and hyperextension (face) along a longitudinal axis. The presenting portion of the fetal head is between the orbital ridge and the anterior fontanel. The face and chin are not included. The frontal bones are the point of designation and can present (as with the occiput during a vertex delivery) in any position relative to the maternal pelvis. When the sagittal suture is transverse to the pelvic axis and the anterior fontanel is on the right maternal side, the fetus would be in the right frontotransverse position (RFT).

Face presentation occurs in 1 of every 600-800 live births, averaging about 0.2% of live births. Causative factors associated with a face presentation are similar to those leading to general malpresentation and those that prevent head flexion or favor extension. Possible etiology includes multiple gestations, grand multiparity, fetal malformations, prematurity, and cephalopelvic disproportion. At least one etiological factor may be identified in up to 90% of cases with face presentation.

Fetal anomalies such as hydrocephalus, anencephaly, and neck masses are common risk factors and may account for as many as 60% of cases of face presentation. For example, anencephaly is found in more than 30% of cases of face presentation. Fetal thyromegaly and neck masses also lead to extension of the fetal head.

A contracted pelvis or cephalopelvic disproportion, from either a small pelvis or a large fetus, occurs in 10-40% of cases. Multiparity or a large abdomen can cause decreased uterine tone, leading to natural extension of the fetal head.

Face presentation is diagnosed late in the first or second stage of labor by examination of a dilated cervix. On digital examination, the distinctive facial features of the nose, mouth, and chin, the malar bones, and particularly the orbital ridges can be palpated. This presentation can be confused with a breech presentation because the mouth may be confused with the anus and the malar bones or orbital ridges may be confused with the ischial tuberosities. The facial presentation has a triangular configuration of the mouth to the orbital ridges compared to the breech presentation of the anus and fetal genitalia. During Leopold maneuvers, diagnosis is very unlikely. Diagnosis can be confirmed by ultrasound evaluation, which reveals a hyperextended fetal neck. [ 1 , 2 ]

Brow presentation is the least common of all fetal presentations and the incidence varies from 1 in 500 deliveries to 1 in 1400 deliveries. Brow presentation may be encountered early in labor but is usually a transitional state and converts to a vertex presentation after the fetal neck flexes. Occasionally, further extension may occur resulting in a face presentation.

The causes of a persistent brow presentation are generally similar to those causing a face presentation and include cephalopelvic disproportion or pelvic contracture, increasing parity and prematurity. These are implicated in more than 60% of cases of persistent brow presentation. Premature rupture of membranes may precede brow presentation in as many as 27% of cases.

Diagnosis of a brow presentation can occasionally be made with abdominal palpation by Leopold maneuvers. A prominent occipital prominence is encountered along the fetal back, and the fetal chin is also palpable; however, the diagnosis of a brow presentation is usually confirmed by examination of a dilated cervix. The orbital ridge, eyes, nose, forehead, and anterior fontanelle are palpated. The mouth and chin are not palpable, thus excluding face presentation. Fetal ultrasound evaluation again notes a hyperextended neck.

As with face presentation, diagnosis is often made late in labor with half of cases occurring in the second stage of labor. The most common position is the mentum anterior, which occurs about twice as often as either transverse or posterior positions. A higher cesarean delivery rate occurs with a mentum transverse or posterior [ 3 ] position than with a mentum anterior position.

The mechanism of labor consists of the cardinal movements of engagement, descent, flexion, internal rotation, and the accessory movements of extension and external rotation. Intuitively, the cardinal movements of labor for a face presentation are not completely identical to those of a vertex presentation.

While descending into the pelvis, the natural contractile forces combined with the maternal pelvic architecture allow the fetal head to either flex or extend. In the vertex presentation, the vertex is flexed such that the chin rests on the fetal chest, allowing the suboccipitobregmatic diameter of approximately 9.5 cm to be the widest diameter through the maternal pelvis. This is the smallest of the diameters to negotiate the maternal pelvis. Following engagement in the face presentation, descent is made. The widest diameter of the fetal head negotiating the pelvis is the trachelobregmatic or submentobregmatic diameter, which is 10.2 cm (0.7 cm larger than the suboccipitobregmatic diameter). Because of this increased diameter, engagement does not occur until the face is at +2 station.

Fetuses with face presentation may initially begin labor in the brow position. Using x-ray pelvimetry in a series of 7 patients, Borrell and Ferstrom demonstrated that internal rotation occurs between the ischial spines and the ischial tuberosities, making the chin the presenting part, lower than in the vertex presentation. [ 4 , 5 ] Following internal rotation, the mentum is below the maternal symphysis, and delivery occurs by flexion of the fetal neck. As the face descends onto the perineum, the anterior fetal chin passes under the symphysis and flexion of the head occurs, making delivery possible with maternal expulsive forces.

The above mechanisms of labor in the term infant can occur only if the mentum is anterior and at term, only the mentum anterior face presentation is likely to deliver vaginally. If the mentum is posterior or transverse, the fetal neck is too short to span the length of the maternal sacrum and is already at the point of maximal extension. The head cannot deliver as it cannot extend any further through the symphysis and cesarean delivery is the safest route of delivery.

Fortunately, the mentum is anterior in over 60% of cases of face presentation, transverse in 10-12% of cases, and posterior only 20-25% of the time. Fetuses with the mentum transverse position usually rotate to the mentum anterior position, and 25-33% of fetuses with mentum posterior position rotate to a mentum anterior position. When the mentum is posterior, the neck, head and shoulders must enter the pelvis simultaneously, resulting in a diameter too large for the maternal pelvis to accommodate unless in the very preterm or small infant.

Three labor courses are possible when the fetal head engages in a brow presentation. The brow may convert to a vertex presentation, to a face presentation, or remain as a persistent brow presentation. More than 50% of brow presentations will convert to vertex or face presentation and labor courses are managed accordingly when spontaneous conversion occurs.

In the brow presentation, the occipitomental diameter, which is the largest diameter of the fetal head, is the presenting portion. Descent and internal rotation occur only with an adequate pelvis and if the face can fit under the pubic arch. While the head descends, it becomes wedged into the hollow of the sacrum. Downward pressure from uterine contractions and maternal expulsive forces may cause the mentum to extend anteriorly and low to present at the perineum as a mentum anterior face presentation.

If internal rotation does not occur, the occipitomental diameter, which measures 1.5 cm wider than the suboccipitobregmatic diameter and is thus the largest diameter of the fetal head, presents at the pelvic inlet. The head may engage but can descend only with significant molding. This molding and subsequent caput succedaneum over the forehead can become so extensive that identification of the brow by palpation is impossible late in labor. This may result in a missed diagnosis in a patient who presents later in active labor.

If the mentum is anterior and the forces of labor are directed toward the fetal occiput, flexing the head and pivoting the face under the pubic arch, there is conversion to a vertex occiput posterior position. If the occiput lies against the sacrum and the forces of labor are directed against the fetal mentum, the neck may extend further, leading to a face presentation.

The persistent brow presentation with subsequent delivery only occurs in cases of a large pelvis and/or a small infant. Women with gynecoid pelvis or multiparity may be given the option to labor; however, dysfunctional labor and cephalopelvic disproportion are more likely if this presentation persists.

Labor management of face and brow presentation requires close observation of labor progression because cephalopelvic disproportion, dysfunctional labor, and prolonged labor are much more common. As mentioned above, the trachelobregmatic or submentobregmatic diameters are larger than the suboccipitobregmatic diameter. Duration of labor with a face presentation is generally the same as duration of labor with a vertex presentation, although a prolonged labor may occur. As long as maternal or fetal compromise is not evident, labor with a face presentation may continue. [ 6 ] A persistent mentum posterior presentation is an indication for delivery by cesarean section.

Continuous electronic fetal heart rate monitoring is considered mandatory by many authors because of the increased incidence of abnormal fetal heart rate patterns and/or nonreassuring fetal heart rate patterns. [ 7 ] An internal fetal scalp electrode may be used, but very careful application of the electrode must be ensured. The mentum is the recommended site of application. Facial edema is common and can obscure the fetal facial anatomy and improper placement can lead to facial and ophthalmic injuries. Oxytocin can be used to augment labor using the same precautions as in a vertex presentation and the same criteria of assessment of uterine activity, adequacy of the pelvis, and reassuring fetal heart tracing.

Fetuses with face presentation can be delivered vaginally with overall success rates of 60-70%, while more than 20% of fetuses with face presentation require cesarean delivery. Cesarean delivery is performed for the usual obstetrical indications, including arrest of labor and nonreassuring fetal heart rate pattern.

Attempts to manually convert the face to vertex (Thom maneuver) or to rotate a posterior position to a more favorable anterior mentum position are rarely successful and are associated with high fetal morbidity and mortality and maternal morbidity, including cord prolapse, uterine rupture, and fetal cervical spine injury with neurological impairment. Given the availability and safety of cesarean delivery, internal rotation maneuvers are no longer justified unless cesarean section cannot be readily performed.

Internal podalic version and breech extraction are also no longer recommended in the modern management of the face presentation. [ 8 ]

Operative delivery with forceps must be approached with caution. Since engagement occurs when the face is at +2 position, forceps should only be applied to the face that has caused the perineum to bulge. Increased complications to both mother and fetus can occur [ 9 ] and operative delivery must be approached with caution or reserved when cesarean section is not readily available. Forceps may be used if the mentum is anterior. Although the landmarks are different, the application of any forceps is made as if the fetus were presenting directly in the occiput anterior position. The mouth substitutes for the posterior fontanelle, and the mentum substitutes for the occiput. Traction should be downward to maintain extension until the mentum passes under the symphysis, and then gradually elevated to allow the head to deliver by flexion. During delivery, hyperextension of the fetal head should be avoided.

As previously mentioned, the persistent brow presentation has a poor prognosis for vaginal delivery unless the fetus is small, premature, or the maternal pelvis is large. Expectant management is reasonable if labor is progressing well and the fetal well-being is assessed, as there can be spontaneous conversion to face or vertex presentation. The earlier in labor that brow presentation is diagnosed, the higher the likelihood of conversion. Minimal intervention during labor is recommended and some feel the use of oxytocin in the brow presentation is contraindicated.

The use of operative vaginal delivery or manual conversion of a brow to a more favorable presentation is contraindicated as the risks of perinatal morbidity and mortality are unacceptably high. Prolonged, dysfunctional, and arrest of labor are common, necessitating cesarean section delivery.

The incidence of perinatal morbidity and mortality and maternal morbidity has decreased due to the increased incidence of cesarean section delivery for malpresentation, including face and brow presentation.

Neonates delivered in the face presentation exhibit significant facial and skull edema, which usually resolves within 24-48 hours. Trauma during labor may cause tracheal and laryngeal edema immediately after delivery, which can result in neonatal respiratory distress. In addition, fetal anomalies or tumors, such as fetal goiters that may have contributed to fetal malpresentation, may make intubation difficult. Physicians with expertise in neonatal resuscitation should be present at delivery in the event that intubation is required. When a fetal anomaly has been previously diagnosed by ultrasonographic evaluation, the appropriate pediatric specialists should be consulted and informed at time of labor.

Bellussi F, Ghi T, Youssef A, et al. The use of intrapartum ultrasound to diagnose malpositions and cephalic malpresentations. Am J Obstet Gynecol . 2017 Dec. 217 (6):633-41. [QxMD MEDLINE Link] .

[Guideline] Ghi T, Eggebø T, Lees C, et al. ISUOG Practice Guidelines: intrapartum ultrasound. Ultrasound Obstet Gynecol . 2018 Jul. 52 (1):128-39. [QxMD MEDLINE Link] . [Full Text] .

Shaffer BL, Cheng YW, Vargas JE, Laros RK Jr, Caughey AB. Face presentation: predictors and delivery route. Am J Obstet Gynecol . 2006 May. 194(5):e10-2. [QxMD MEDLINE Link] .

Borell U, Fernstrom I. The mechanism of labour. Radiol Clin North Am . 1967 Apr. 5(1):73-85. [QxMD MEDLINE Link] .

Borell U, Fernstrom I. The mechanism of labour in face and brow presentation: a radiographic study. Acta Obstet Gynecol Scand . 1960. 39:626-44.

Gardberg M, Leonova Y, Laakkonen E. Malpresentations--impact on mode of delivery. Acta Obstet Gynecol Scand . 2011 May. 90(5):540-2. [QxMD MEDLINE Link] .

Collaris RJ, Oei SG. External cephalic version: a safe procedure? A systematic review of version-related risks. Acta Obstet Gynecol Scand . 2004 Jun. 83(6):511-8. [QxMD MEDLINE Link] .

Verspyck E, Bisson V, Gromez A, Resch B, Diguet A, Marpeau L. Prophylactic attempt at manual rotation in brow presentation at full dilatation. Acta Obstet Gynecol Scand . 2012 Nov. 91(11):1342-5. [QxMD MEDLINE Link] .

Johnson JH, Figueroa R, Garry D. Immediate maternal and neonatal effects of forceps and vacuum-assisted deliveries. Obstet Gynecol . 2004 Mar. 103(3):513-8. [QxMD MEDLINE Link] .

Benedetti TJ, Lowensohn RI, Truscott AM. Face presentation at term. Obstet Gynecol . 1980 Feb. 55(2):199-202. [QxMD MEDLINE Link] .

BROWNE AD, CARNEY D. OBSTETRICS IN GENERAL PRACTICE. MANAGEMENT OF MALPRESENTATIONS IN OBSTETRICS. Br Med J . 1964 May 16. 1(5393):1295-8. [QxMD MEDLINE Link] .

Campbell JM. Face presentation. Aust N Z J Obstet Gynaecol . 1965 Nov. 5(4):231-4. [QxMD MEDLINE Link] .

Contributor Information and Disclosures

Teresa Marino, MD Assistant Professor, Attending Physician, Division of Maternal-Fetal Medicine, Tufts Medical Center Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference Disclosure: Received salary from Medscape for employment. for: Medscape.

Carl V Smith, MD The Distinguished Chris J and Marie A Olson Chair of Obstetrics and Gynecology, Professor, Department of Obstetrics and Gynecology, Senior Associate Dean for Clinical Affairs, University of Nebraska Medical Center Carl V Smith, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists , American Institute of Ultrasound in Medicine , Association of Professors of Gynecology and Obstetrics , Central Association of Obstetricians and Gynecologists , Society for Maternal-Fetal Medicine , Council of University Chairs of Obstetrics and Gynecology , Nebraska Medical Association Disclosure: Nothing to disclose.

Chitra M Iyer, MD, Perinatologist, Obstetrix Medical Group, Fort Worth, Texas.

Chitra M Iyer, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists , Society of Maternal-Fetal Medicine .

Disclosure: Nothing to disclose.

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Obstetrics Simplified - Diaa M. EI-Mowafi

Face Presentation

It is a cephalic presentation in which the head is completely extended.

About 1:300 labours.

• It is less common.
• It occurs during pregnancy.
• Anencephaly: due to absence of the bony vault of the skull and the scalp while the facial portion is normal.
• Loops of the cord around the neck.
• Tumours of the foetal neck e.g. congenital goitre.
• Hypertonicity of the extensor muscles of the neck.
• Dolicocephaly: long antero-posterior diameter of the head, so as the breadth is less than 4/5 of the length.
• Dead or premature foetus.
• Idiopathic.
• It is more common. 
• It occurs during labour.
• Contracted pelvis particularly flat pelvis which allows descent of the bitemporal but not the biparietal diameter leads to extension of the head.
• Pendulous abdomen or marked lateral obliquity of the uterus.
• Further deflexion of brow or occipito - posterior positions.
• Other causes of malpresentations as polyhydramnios and placenta praevia.
• Right mento-posterior (RMP).           
• Left mento-posterior (LMP).
• Left mento-anterior (LMA).
• Right mento-anterior (RMA), are the more common positions.
• Right mento-transverse (lateral), left mento-transverse, direct mento-posterior and direct mento-anterior are rare and usually transient positions.

The first position (RMP) corresponds to the first normal position (LOA) as the back should be to the left and anterior in the first position. Mento-anterior are more common than mento-posterior as most cases arise from more deflexion of the head in occipito-posterior position usually in flat contracted pelvis.

During pregnancy (difficult)

• The back is difficult to feel.
• The limbs are felt more prominent in mento-anterior position.
• The chin may be felt on the same side of the limbs as a horseshoe-shaped rim in mento-anterior position.
• In mento-posterior, a groove may be felt between the occiput and the back particularly after rupture of the membranes.
• Second pelvic grip: the occiput is at a higher level than the sinciput.
• The FHS are heard below the umbilicus through the foetal chest wall in mento-anterior position.
• Ultrasound or X-ray: confirms the diagnosis and may identify associated foetal anomalies as anencephaly.

During labour

Vaginal examination shows the following identifying features for face:

• supra-orbital ridges,
• the malar processes,
• the nose (rubbery and saddle shaped),
• the mouth with hard areolar ridges.

Late in labour, the face becomes oedematous (tumefaction) so it can be misdiagnosed as a buttock (breech presentation) where the two cheeks are mistaken with buttocks and the mouth with anus and the malar processes with the ischial tuberosities. The following points can differentiate in-between:

Mechanism of Labour

Mento-anterior position

• Engagement by submento-bregmatic diameter 9.5 cm.
• Increased extension.
• Internal rotation of chin 1/8 circle anteriorly.
• Flexion: is the movement by which the head is delivered in mento-anterior position when the submental region hinges below the symphysis. The vulva is much distended by the submento-vertical diameter 11.5 cm.
• Restitution.
• External rotation.

Engagement is delayed because:

• The biparietal diameter does not pass the plane of pelvic inlet until the chin is below the level of the ischial spines and the face begins to distend the perineum.
• Moulding does not occur as in vertex presentation.

Mento-posterior position

• so the head is delivered as mento-anterior.
• Deep transverse arrest of the face: when the chin rotates 1/8 circle anteriorly.
• Persistent mento-posterior: when no rotation occurs.
• Direct mento-posterior: When the chin rotates 1/8 circle posteriorly.

In the last 3 conditions no further progress occurs and labour is obstructed.

Direct mento-posterior, unlike direct occipito-posterior, cannot be delivered because:

• Delivery should occur by extension while the head is already maximally extended.
• As the length of the sacrum is 10 cm and that of neck is only 5 cm, the shoulders enter the pelvis and become impacted while the head still in the pelvis, thus the labour is obstructed.

Management of Labour

Exclude: - Foetal anomalies and - Contracted pelvis.

Mento-anterior

• First stage: as in occipito-posterior.
• Spontaneous delivery usually occurs.
• Forceps delivery may be indicated in prolonged 2nd stage.
• Episiotomy is necessary because of over distension of the vulva.

Mento-posterior

• First stage: as mento-anterior.
• Wait for long anterior rotation of the mentum 3/8 circle and the head will be delivered as mento-anterior. During this period oxytocin is used to compete inertia which is common in such conditions as long as there is no contraindication. Failure of this long rotation is more common than in occipito-posterior position so earlier interference is usually indicated.
• Caesarean section: which is the safest and the current alternative in modern obstetrics.
• Manual rotation and forceps extraction as mento-anterior, or
• Rotation and extraction by Kielland forceps.
• In the last 2 methods the head should be engaged but they are hazardous to both the mother and foetus so they are nearly out of modern obstetrics.
• Craniotomy: if the foetus is dead.

The face of the foetus is oedematous after delivery so the mother is assured that this will be spontaneously relieved within few days.

Complications

See complications of malpresentations and malposition.

• Dystocia : Guidelines, reviews

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Management of face presentation, face and lip edema in a primary healthcare facility case report, Mbengwi, Cameroon

Nzozone henry fomukong.

1 Microhealth Global Medical Centre, Mbengwi, Cameroon

2 Department of Medicine and Surgery, Faculty of Health Sciences University of Buea, Buea, Cameroon

Ngouagna Edwin

Mandeng ma linwa edgar, ngwayu claude nkfusai.

3 Department of Microbiology and Parasitology, Faculty of Science, University of Buea, Buea, Cameroon

4 Cameroon Baptist Convention Health Services (CBCHS), Yaoundé, Cameroon

Yunga Patience Ijang

5 Department of Public Health, School of Health Sciences, Catholic University of Central Africa, Box 1110, Yaoundé, Cameroon

Joyce Shirinde

6 School of Health Systems and Public Health, Faculty of Health Sciences, University of Pretoria Private Bag X323, Gezina, Pretoria, 0001, Pretoria, South Africa

Samuel Nambile Cumber

7 Institute of Medicine, Department of Public Health and Community Medicine (EPSO), University of Gothenburg, Box 414, SE - 405 30 Gothenburg, Sweden

8 Faculty of Health Sciences, University of the Free State, Bloemfontein, South Africa

Face presentation is a rare obstetric event and most practitioners will go through their carriers without ever meeting one. Face presentation can be delivered vaginally only if the foetus is in the mentum anterior position. More than half of the cases of face presentation are delivered by caesarean section. Newborn infants with face presentation usually have severe facial oedema, facial bruising or ecchymosis. These syndromic facial features usually resolved within 24-48 hours.

Introduction

Face presentation is a rare unanticipated obstetric event characterized by a longitudinal lie and full extension of the foetal head on the neck with the occiput against the upper back [ 1 - 3 ]. Face presentation occurs in 0.1-0.2% of deliveries [ 3 - 5 ] but is more common in black women and in multiparous women [ 5 ]. Studies have shown that 60 per cent of face presentations have one or more of the following risk factors: small fetus, large fetus, high parity, previous caesarean section (CS), contracted pelvis, fetopelvic disproportion, cord around the neck multiple pregnancy, hypertensive disorders of pregnancy, polyhydramnios, uterine or nuchal cord anomaly. But 40 per cent of face presentations occur with none of these factors [ 6 , 7 ]. A vaginal birth at term is possible only if the fetus is in the mentum anterior position. More than half of cases of face presentation are delivered by caesarean section [ 4 ]. Newborn infants with face presentation usually have severe facial edema, facial bruising or ecchymosis [ 8 ]. Repeated vaginal examination to assess the presenting part and the progress of labor may lead to bruises in the face as well as damage to the eyes.

Patient and observation

Case presentation: a 21 year old primigravida at 40 weeks gestation from the last normal menstrual period referred to our facility for prolonged second stage of labor after visiting two health centres. She labored for a total of 14hrs, membrane ruptured spontaneously 12hrs before referral. Amniotic fluid was documented by midwife to be clear. She attended antenatal clinics in Mbengwi health centre 5 times, was diagnosed of hepatitis B during antenatal consultations, received no treatment. She did not do any ultrasound due to financial constraints. On examination, she was healthy, in painful distress, blood pressure 131/76mmhg, pulse 85 beats/min, temperature 37.2 o C SPO2 98%. On abdominal exams, uterus was gravid, fundal height 35cm, lie longitudinal, fetal heart rate 137bpm, cephalic presentation, engaged 2/5, with moderate contractions of 2 in 10 minutes. On vaginal examination, cervix was fully dilated, membranes ruptured, presenting part was face, mentum anterior. The conclusion made was mento-anterior face presentation ( Figure 1 ). Paturient was counseled, labor was augmented with 1 amp of oxytocin in 500ml of glucose 5% and started at 10drops/mins. Ten minutes later she delivered a male baby with Apgar score 6/10, 8/10 on the first and fifth minute. The baby weighed 3.2kg, length was 50cm, and head circumference was 41cm. Syndromic facial appearance with marked edema at the baby's lips, face and scalp was evident and he had bruising on the right nasolabial groove and right cheeks ( Figure 2 ). Physical examination of the infant's respiratory system, cardiovascular system, and his abdominal examination were normal, as was his neurological examination. Placenta was delivered by controlled cord traction 5mins later with all cotyledons. Delivery was complicated by a second degree perineal tear. Perineal tear was repaired with absorbable suture under local anaesthesia. Estimated blood lost was 350ml. baby received Hepatitis B immunoglobulins, hepatitis B vaccine and vitamin K were administered to the baby. 24 hours later, facial swellings resolved ( Figure 3 ), baby breast feeds well. Baby and mother were discharged on day 3 postpartum all fine.

Men-tum anterior face presentation

Bruising, marked lip and facial edema

Baby 24 hours later with all syndromic facial features resolved

Ethics : informed consent: written informed consent was obtained from the patient's parents for the publication of this case report.

Face presentation is a rare obstetric event and most practitioner will go through their carriers without ever meeting one [ 3 ]. We presented a case of face presentation noticed in the delivery room on digital examination in a patient with no risk factors. In a poor resource setting as ours where ultrasound is not readily available, this event is often scary and confusing to most midwives and nurses. This may prompt repeated vaginal exams for confirmation of presentation. This intend will lead to bruising of the baby's face and delay effective management [ 8 ]. Exact knowledge about the fetal position and level is important for providing the correct management of this malpresentation. When face presentation is diagnosed, around 60% of cases are in the mentum anterior position, 25% are mentum posterior and 15% are mentum transverse [ 5 ]. The patient presented the most common form of face presentation (mentum anterior). Labor was augmented, vaginal delivery was attempted and successfully conducted. Facial bruising, lip and face edema are very common complication of face presentation. These complications usually resolve within 24-48 hours [ 9 , 10 ] in this case facial edema completely resolved within 24hours ( Figure 3 ) and baby breastfeed well.

Repeated vaginal exams should be avoided when presenting part is unsure. Vaginal delivery should be attemped only on mentum anterior face presentation, in other cases, emergency ceserian section should be performed. Syndromic facial features in babies born from face presentation resolve completely within 24-48 hours.

Competing interests

The authors declare no competing interests.

Acknowledgements

We thank the participant of this study.

Authors’ contributions

NHF, NE, MMLE, NCN, YPI, FB, JS and SNC conceived the case series, assisted with the study design and participant enrollment, designed the study protocol and collected the data. NE, MMLE, NCN and SNC assisted in interpretation of results and wrote the manuscript. All authors read and approved the final manuscript.

7.9 Face presentation

7.9.1 diagnosis.

• Palpation of the mother's abdomen at the start of labour: palpate the occipital region; a cleft between the head and the back will be palpable, due to hyperextension of the head.
• On vaginal examination: no suture or fontanelle can be felt; orbits, nose, mouth, ears and chin palpable. Palpation of the chin is essential to confirm the diagnosis.

7.9.2 Management

Determine the orientation of the chin—anterior (at the mother's pubis) or posterior.

The chin is anterior

Vaginal delivery is possible. Labour may be slow, patience is required. If uterine contractions are inadequate, oxytocin may be used. Episiotomy is usually needed during delivery (Figures 7.4), given the maximum amount the perineum can stretch. If instrumental delivery is necessary, use forceps. Vacuum extraction is contra-indicated for a live fœtus.

Figures 7.4 - Chin anterior: delivery possible

The chin is posterior

Vaginal delivery is not possible (Figure 7.5). A caesarean section must be arranged. Refer if necessary.

Figure 7.5 - Chin posterior: impaction

If caesarean section is not feasible and referral is not possible, attempt the following manoeuvres:

• Flex the head to obtain a vertex presentation: with one hand in the vagina, grasp the top of the skull and flex the neck, using the other hand, on the abdomen, to apply pressure to the foetal chest and buttocks. Obviously, the presenting part must not be engaged, and it is often hard—or impossible—to keep the head flexed (Figures 7.6).

• Rotate the head to bring the chin anteriorly: push the face and chin back to free the shoulders from the pelvic inlet then, turn the head within the pelvic cavity, using a hand on the abdomen to help the rotation by applying pressure to the shoulders. In this way, the chin is brought to the front (Figures 7.7).

• Version: internal podalic version, then total breech extraction (Figure 7.8).

All these manoeuvres are difficult and pose a significant risk of uterine rupture. They must be done when the uterus is not contracting. Whenever possible, caesarean section should be performed instead.

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Delivery, Face and Brow Presentation

Introduction.

The term presentation describes the leading part of the fetus or the anatomical structure closest to the maternal pelvic inlet during labor. The presentation can roughly be divided into the following classifications: cephalic, breech, shoulder, and compound. Cephalic presentation is the most common and can be further subclassified as vertex, sinciput, brow, face, and chin. The most common presentation in term labor is the vertex, where the fetal neck is flexed to the chin, minimizing the head circumference.

Face presentation – an abnormal form of cephalic presentation where the presenting part is mentum. This typically occurs because of hyperextension of the neck and the occiput touching the fetal back. Incidence of face presentation is rare, accounting for approximately 1 in 600 of all presentations. [1] [2] [3]

In brow presentation, the neck is not extended as much as in face presentation, and the leading part is the area between the anterior fontanelle and the orbital ridges. Brow presentation is considered the rarest of all malpresentation with a prevalence of 1 in 500 to 1 in 4000 deliveries. [3]

Both face and brow presentations occur due to extension of the fetal neck instead of flexion; therefore, conditions that would lead to hyperextension or prevent flexion of the fetal neck can all contribute to face or brow presentation. These risk factors may be related to either the mother or the fetus. Maternal risk factors are preterm delivery, contracted maternal pelvis, platypelloid pelvis, multiparity, previous cesarean section, black race. Fetal risk factors include anencephaly, multiple loops of cord around the neck, masses of the neck, macrosomia, polyhydramnios. [2] [4] [5]

These malpresentations are usually diagnosed during the second stage of labor when performing a digital examination. It is possible to palpate orbital ridges, nose, malar eminences, mentum, mouth, gums, and chin in face presentation. Based on the position of the chin, face presentation can be further divided into mentum anterior, posterior, or transverse. In brow presentation, anterior fontanelle and face can be palpated except for the mouth and the chin. Brow presentation can then be further described based on the position of the anterior fontanelle as frontal anterior, posterior, or transverse.

Diagnosing the exact presentation can be challenging, and face presentation may be misdiagnosed as frank breech. To avoid any confusion, a bedside ultrasound scan can be performed. [6]  The ultrasound imaging can show a reduced angle between the occiput and the spine or, the chin is separated from the chest. However, ultrasound does not provide much predicting value in the outcome of the labor. [7]

Anatomy and Physiology

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Before discussing the mechanism of labor in the face or brow presentation, it is crucial to highlight some anatomical landmarks and their measurements. 

Planes and Diameters of the Pelvis

The three most important planes in the female pelvis are the pelvic inlet, mid pelvis, and pelvic outlet. 

Four diameters can describe the pelvic inlet: anteroposterior, transverse, and two obliques. Furthermore, based on the different landmarks on the pelvic inlet, there are three different anteroposterior diameters, named conjugates: true conjugate, obstetrical conjugate, and diagonal conjugate. Only the latter can be measured directly during the obstetric examination. The shortest of these three diameters is obstetrical conjugate, which measures approximately 10.5 cm and is a distance between the sacral promontory and 1 cm below the upper border of the symphysis pubis. This measurement is clinically significant as the fetal head must pass through this diameter during the engagement phase. The transverse diameter measures about 13.5cm and is the widest distance between the innominate line on both sides. 

The shortest distance in the mid pelvis is the interspinous diameter and usually is only about 10 cm. 

Fetal Skull Diameters

There are six distinguished longitudinal fetal skull diameters:

• Suboccipito-bregmatic: from the center of anterior fontanelle (bregma) to the occipital protuberance, measuring 9.5 cm. This is the presenting diameter in vertex presentation. 
• Suboccipito-frontal: from the anterior part of bregma to the occipital protuberance, measuring 10 cm 
• Occipito-frontal: from the root of the nose to the most prominent part of the occiput, measuring 11.5cm
• Submento-bregmatic: from the center of the bregma to the angle of the mandible, measuring 9.5 cm. This is the presenting diameter in face presentation where the neck is hyperextended. 
• Submento-vertical: from the midpoint between fontanelles and the angle of the mandible, measuring 11.5cm 
• Occipito-mental: from the midpoint between fontanelles and the tip of the chin, measuring 13.5 cm. It is the presenting diameter in brow presentation. 

Cardinal Movements of Normal Labor

• Neck flexion
• Internal rotation
• Extension (delivers head)
• External rotation (Restitution)
• Expulsion (delivery of anterior and posterior shoulders)

Some of the key movements are not possible in the face or brow presentations.  

Based on the information provided above, it is obvious that labor will be arrested in brow presentation unless it spontaneously changes to face or vertex, as the occipito-mental diameter of the fetal head is significantly wider than the smallest diameter of the female pelvis. Face presentation can, however, be delivered vaginally, and further mechanisms of face delivery will be explained in later sections.

Indications

As mentioned previously, spontaneous vaginal delivery can be successful in face presentation. However, the main indication for vaginal delivery in such circumstances would be a maternal choice. It is crucial to have a thorough conversation with a mother, explaining the risks and benefits of vaginal delivery with face presentation and a cesarean section. Informed consent and creating a rapport with the mother is an essential aspect of safe and successful labor.

Contraindications

Vaginal delivery of face presentation is contraindicated if the mentum is lying posteriorly or is in a transverse position. In such a scenario, the fetal brow is pressing against the maternal symphysis pubis, and the short fetal neck, which is already maximally extended, cannot span the surface of the maternal sacrum. In this position, the diameter of the head is larger than the maternal pelvis, and it cannot descend through the birth canal. Therefore the cesarean section is recommended as the safest mode of delivery for mentum posterior face presentations. 

Attempts to manually convert face presentation to vertex, manual or forceps rotation of the persistent posterior chin to anterior are contraindicated as they can be dangerous.

Persistent brow presentation itself is a contraindication for vaginal delivery unless the fetus is significantly small or the maternal pelvis is large.

Continuous electronic fetal heart rate monitoring is recommended for face and brow presentations, as heart rate abnormalities are common in these scenarios. One study found that only 14% of the cases with face presentation had no abnormal traces on the cardiotocograph. [8] It is advised to use external transducer devices to prevent damage to the eyes. When internal monitoring is inevitable, it is suggested to place monitoring devices on bony parts carefully. 

People who are usually involved in the delivery of face/ brow presentation are:

• Experienced midwife, preferably looking after laboring woman 1:1
• Senior obstetrician 
• Neonatal team - in case of need for resuscitation 
• Anesthetic team - to provide necessary pain control (e.g., epidural)
• Theatre team  - in case of failure to progress and an emergency cesarean section will be required.

Preparation

No specific preparation is required for face or brow presentation. However, it is essential to discuss the labor options with the mother and birthing partner and inform members of the neonatal, anesthetic, and theatre co-ordinating teams.

Technique or Treatment

Mechanism of Labor in Face Presentation

During contractions, the pressure exerted by the fundus of the uterus on the fetus and pressure of amniotic fluid initiate descent. During this descent, the fetal neck extends instead of flexing. The internal rotation determines the outcome of delivery, if the fetal chin rotates posteriorly, vaginal delivery would not be possible, and cesarean section is permitted. The approach towards mentum-posterior delivery should be individualized, as the cases are rare. Expectant management is acceptable in multiparous women with small fetuses, as a spontaneous mentum-anterior rotation can occur. However, there should be a low threshold for cesarean section in primigravida women or women with large fetuses.

When the fetal chin is rotated towards maternal symphysis pubis as described as mentum-anterior; in these cases further descend through the vaginal canal continues with approximately 73% cases deliver spontaneously. [9] Fetal mentum presses on the maternal symphysis pubis, and the head is delivered by flexion. The occiput is pointing towards the maternal back, and external rotation happens. Shoulders are delivered in the same manner as in vertex delivery.

Mechanism of Labor in Brow Presentation

As this presentation is considered unstable, it is usually converted into a face or an occiput presentation. Due to the cephalic diameter being wider than the maternal pelvis, the fetal head cannot engage; thus, brow delivery cannot take place. Unless the fetus is small or the pelvis is very wide, the prognosis for vaginal delivery is poor. With persistent brow presentation, a cesarean section is required for safe delivery.

Complications

As the cesarean section is becoming a more accessible mode of delivery in malpresentations, the incidence of maternal and fetal morbidity and mortality during face presentation has dropped significantly. [10]

However, there are still some complications associated with the nature of labor in face presentation. Due to the fetal head position, it is more challenging for the head to engage in the birth canal and descend, resulting in prolonged labor.

Prolonged labor itself can provoke foetal distress and arrhythmias. If the labor arrests or signs of fetal distress appear on CTG, the recommended next step in management is an emergency cesarean section, which in itself carries a myriad of operative and post-operative complications.

Finally, due to the nature of the fetal position and prolonged duration of labor in face presentation, neonates develop significant edema of the skull and face. Swelling of the fetal airway may also be present, resulting in respiratory distress after birth and possible intubation.

Clinical Significance

During vertex presentation, the fetal head flexes, bringing the chin to the chest, forming the smallest possible fetal head diameter, measuring approximately 9.5cm. With face and brow presentation, the neck hyperextends, resulting in greater cephalic diameters. As a result, the fetal head will engage later, and labor will progress more slowly. Failure to progress in labor is also more common in both presentations compared to vertex presentation.

Furthermore, when the fetal chin is in a posterior position, this prevents further flexion of the fetal neck, as browns are pressing on the symphysis pubis. As a result, descend through the birth canal is impossible. Such presentation is considered undeliverable vaginally and requires an emergency cesarean section.

Manual attempts to change face presentation to vertex, manual or forceps rotation to mentum anterior are considered dangerous and are discouraged.

Enhancing Healthcare Team Outcomes

A multidisciplinary team of healthcare experts supports the woman and her child during labor and the perinatal period. For a face or brow presentation to be appropriately diagnosed, an experienced midwife and obstetrician must be involved in the vaginal examination and labor monitoring. As fetal anomalies, such as anencephaly or goiter, can contribute to face presentation, sonographers experienced in antenatal scanning should also be involved in the care. It is advised to inform the anesthetic and neonatal teams in advance of the possible need for emergency cesarean section and resuscitation of the neonate. [11] [12]

Gardberg M,Leonova Y,Laakkonen E, Malpresentations--impact on mode of delivery. Acta obstetricia et gynecologica Scandinavica. 2011 May;     [PubMed PMID: 21501123]

Tapisiz OL,Aytan H,Altinbas SK,Arman F,Tuncay G,Besli M,Mollamahmutoglu L,Danışman N, Face presentation at term: a forgotten issue. The journal of obstetrics and gynaecology research. 2014 Jun;     [PubMed PMID: 24888918]

Zayed F,Amarin Z,Obeidat B,Obeidat N,Alchalabi H,Lataifeh I, Face and brow presentation in northern Jordan, over a decade of experience. Archives of gynecology and obstetrics. 2008 Nov;     [PubMed PMID: 18283473]

Bashiri A,Burstein E,Bar-David J,Levy A,Mazor M, Face and brow presentation: independent risk factors. The journal of maternal-fetal     [PubMed PMID: 18570114]

Shaffer BL,Cheng YW,Vargas JE,Laros RK Jr,Caughey AB, Face presentation: predictors and delivery route. American journal of obstetrics and gynecology. 2006 May;     [PubMed PMID: 16647888]

Bellussi F,Ghi T,Youssef A,Salsi G,Giorgetta F,Parma D,Simonazzi G,Pilu G, The use of intrapartum ultrasound to diagnose malpositions and cephalic malpresentations. American journal of obstetrics and gynecology. 2017 Dec;     [PubMed PMID: 28743440]

Ghi T,Eggebø T,Lees C,Kalache K,Rozenberg P,Youssef A,Salomon LJ,Tutschek B, ISUOG Practice Guidelines: intrapartum ultrasound. Ultrasound in obstetrics     [PubMed PMID: 29974596]

Benedetti TJ,Lowensohn RI,Truscott AM, Face presentation at term. Obstetrics and gynecology. 1980 Feb;     [PubMed PMID: 7352081]

Ducarme G,Ceccaldi PF,Chesnoy V,Robinet G,Gabriel R, [Face presentation: retrospective study of 32 cases at term]. Gynecologie, obstetrique     [PubMed PMID: 16630740]

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Domingues AP,Belo A,Moura P,Vieira DN, Medico-legal litigation in Obstetrics: a characterization analysis of a decade in Portugal. Revista brasileira de ginecologia e obstetricia : revista da Federacao Brasileira das Sociedades de Ginecologia e Obstetricia. 2015 May;     [PubMed PMID: 26107576]

. Intrapartum care for healthy women and babies. 2022 Dec 14:():     [PubMed PMID: 32212591]

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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 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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Face presentation is defined as a cephalic presentation in which the presenting part is face and it occurs due to factors that lead to extension of of fetal head. It is a rare obstetric presentation and may not be encountered even in the entire carrier of an obstetrician.

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Shaffer BL. Face presentation: predictors and delivery route. Am J Obstet Gynecol. 2006;194:e10–2.

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Schwartz Z, Dgani R, Lancet M, Kessler I. Face presentation. Aust N Z J Obstet Gynaecol. 1986;26:172–6.

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Westgren M, et al. Face presentation in modern obstetrics-a study with special reference to fetal long term morbidity. Z Geburtshilfe Perinatol. 1984;188(2):87–9.

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Agarwal, S., Pandit, S. (2023). Face Presentation. In: Garg, R. (eds) Labour and Delivery. Springer, Singapore. https://doi.org/10.1007/978-981-19-6145-8_6

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Delivery, Face Presentation, and Brow Presentation: Understanding Fetal Positions and Birth Scenarios

Introduction:.

During childbirth, the position of the baby plays a significant role in the delivery process. While the most common fetal presentation is the head-down position (vertex presentation), variations can occur, such as face presentation and brow presentation. This comprehensive article aims to provide a thorough understanding of delivery, face presentation, and brow presentation, including their definitions, causes, complications, and management approaches.

Delivery Process:

• Normal Vertex Presentation: In a typical delivery, the baby is positioned head-down, with the back of the head (occiput) leading the way through the birth canal.
• Engagement and Descent: Prior to delivery, the baby's head engages in the pelvis and gradually descends, preparing for birth.
• Cardinal Movements: The baby undergoes a series of cardinal movements, including flexion, internal rotation, extension, external rotation, and restitution, which facilitate the passage through the birth canal.

Face Presentation:

• Definition: Face presentation occurs when the baby's face is positioned to lead the way through the birth canal instead of the vertex (head).
• Causes: Face presentation can occur due to factors such as abnormal fetal positioning, multiple pregnancies, uterine abnormalities, or maternal pelvic anatomy.
• Complications: Face presentation is associated with an increased risk of prolonged labor, difficulties in delivery, increased fetal malposition, birth injuries, and the need for instrumental delivery.
• Management: The management of face presentation depends on several factors, including the progression of labor, the size of the baby, and the expertise of the healthcare provider. Options may include closely monitoring the progress of labor, attempting a vaginal delivery with careful maneuvers, or considering a cesarean section if complications arise.

Brow Presentation:

• Definition: Brow presentation occurs when the baby's head is partially extended, causing the brow (forehead) to lead the way through the birth canal.
• Causes: Brow presentation may result from abnormal fetal positioning, poor engagement of the fetal head, or other factors that prevent full flexion or extension.
• Complications: Brow presentation is associated with a higher risk of prolonged labor, difficulty in descent, increased chances of fetal head entrapment, birth injuries, and the potential need for instrumental delivery or cesarean section.
• Management: The management of brow presentation depends on various factors, such as cervical dilation, progress of labor, fetal size, and the presence of complications. Close monitoring, expert assessment, and a multidisciplinary approach may be necessary to determine the safest delivery method, which can include vaginal delivery with careful maneuvers, instrumental assistance, or cesarean section if warranted.

Delivery Techniques and Intervention:

• Obstetric Maneuvers: In certain situations, skilled healthcare providers may use obstetric maneuvers, such as manual rotation or the use of forceps or vacuum extraction, to facilitate delivery, reposition the baby, or prevent complications.
• Cesarean Section: In cases where vaginal delivery is not possible or poses risks to the mother or baby, a cesarean section may be performed to ensure a safe delivery.

Conclusion:

Delivery, face presentation, and brow presentation are important aspects of childbirth that require careful management and consideration. Understanding the definitions, causes, complications, and appropriate management approaches associated with these fetal positions can help healthcare providers ensure safe and successful deliveries. Individualized care, close monitoring, and multidisciplinary collaboration are crucial in optimizing maternal and fetal outcomes during these unique delivery scenarios.

Hashtags: #Delivery #FacePresentation #BrowPresentation #Childbirth #ObstetricDelivery

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Management of Brow, Face, and Compound Malpresentations

Author: Meera Kesavan, MD

Mentor: Lisa Keder MD Editor: Daniel JS Martingano DO MBA PhD

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Fetal malpresentation, including brow, face, or compound presentations, complicates around 3-4% of all term births. Because these abnormal fetal presentations still are cephalic, many such cases result in vaginal deliveries, yet there are increased risks for adverse outcomes, including cesarean delivery resultant surgical complications, persistent malpresentation precluding vaginal delivery, and abnormal labor resulting in arrest of dilation or descent.

These fetal malpresentation are differentiated in the following ways:

• In face presentations, the presenting part is the mentum, which is further divided based on its position, including mentum posterior, mentum transverse or mentum anterior positions. This typically occurs because of hyperextension of the neck and the occiput touching the fetal back. Mentum anterior malpresentations can potentially achieve vaginal deliveries, whereas mentum posterior malpresentations cannot.
• In brow presentations, there is less extension of the fetal neck as in face presentations making the leading fetal part being the area between the anterior fontanelle and the orbital ridges. These presentations are uncommon and are managed similarly to face presentations. Brow presentation can be further described based on the position of the anterior fontanelle as frontal anterior, posterior, or transverse.
• Compound presentation is defined as the leading fetal part, including a fetal extremity, alongside a cephalic or breech presentation. Management of compound presentations is expected (and often incidentally noted following delivery) because the extremity will often either retract as the head descends or will feasibly allow for delivery in its current position, with manipulation attempts to reduce the compound presentation usually avoided.

Risk factors for brow and face presentations include fetal CNS malformations, congenital or chromosomal anomalies, advanced maternal age, low birthweight, abnormal maternal pelvic anatomy (e.g. contracted pelvis, cephalopelvic disporotion, platypelloid pelvis, etc.) and nulliparity. non-Hispanic White women have the highest risk for malpresentation, whereas non-Hispanic Black women have the lowest risk.

Diagnosis usually is made during the second stage of labor while performing routine vaingla examinations and involves palpation of the abnormal leading fetal part (forehead, orbital ridge, orbits, nose, etc.) Obstetric ultrasound can additionally provide complimentary information to support these diagnoses and distinguish from other fetal malpresentations or malpositions. In face presentation, the mentum (chin) and mouth are palpable.

Management considerations for face, brow, and compounds presentations are unique with compound presentations having higher rates of vaginal delivery and lower complications as compared to either brow or face presentations.

• For brow presentations, approximately 30-40% of brow presentations will convert to a face presentation, and about 20% will convert to a vertex presentation. Anterior positions have the possibility of vaginal deliveries and can be managed by usual labor management principles, whereas mentum posterior positions are indications for cesarean delivery.
• For face presentations, the likelihood of vaginal delivery depends on the orientation of the mentum, with mentum anterior being most suitable for vaginal delivery. If the fetus is mentum posterior, flexion of the neck is precluded and results in the inability of fetal descent.
• For compound presentations, management is expectant and manipulation of the leading extremities should be avoided. Most cases of compound presentation result in vaginal deliveries. For term deliveries, compound presentations with parts other than the hand are unlikely to result in safe vaginal delivery.

Labor management for brow and face presentation overall involves continuous fetal heart rate monitoring and repeat clinical assessments, given the increased potential of fetal complications as noted. Caution should be used with internal monitoring devices, which can cause ophthalmic injury or trauma to the presenting fetal parts, with the use of fetal scalp electrodes discouraged and intrauterine pressure catheters acceptable with appropriate clinical judgment and feasibility.

Midforceps, breech extraction, and manual manipulation are not recommended and increase the risk of maternal and neonatal morbidity. 

Neonatal outcomes for both face and brow presentations include facial edema, bruising, and soft tissue trauma. Complications of compound presentation specifically include umbilical cord prolapse and injury to the presenting limb. With appropriate management, neonatal and maternal morbidity for face, brow, and compound presentations are low.

Further Reading:

Bar-El L, Eliner Y, Grunebaum A, Lenchner E, et al. Race and ethnicity are among the predisposing factors for fetal malpresentation at term. Am J Obstet Gynecol MFM. 2021 Sep;3(5):100405. doi: 10.1016/j.ajogmf.2021.100405. Epub 2021 Jun 4. PMID: 34091061.

Bellussi F, Ghi T, Youssef A, et al. The use of intrapartum ultrasound to diagnose malpositions and cephalic malpresentations. Am J Obstet Gynecol. 2017 Dec;217(6):633-641. doi: 10.1016/j.ajog.2017.07.025. Epub 2017 Jul 22. PMID: 28743440 . 

Pilliod RA, Caughey AB. Fetal Malpresentation and Malposition: Diagnosis and Management. Obstet Gynecol Clin North Am. 2017 Dec;44(4):631-643. doi: 10.1016/j.ogc.2017.08.003. PMID: 29078945 .

Zayed F, Amarin Z, Obeidat B, et al. Face and brow presentation in northern Jordan, over a decade of experience. Arch Gynecol Obstet. 2008 Nov;278(5):427-30. doi: 10.1007/s00404-008-0600-0. Epub 2008 Feb 19. PMID: 18283473 . 

Initial Approval: August 2013; Revised: 11/2016; Revised July 2018; Reaffirmed January 2020; Revised September 2021. Revised July 2023.

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Diagnosis and management of face presentation

• PMID: 7005774

Face presentation is an unusual complication of pregnancy; it occurs once in every 500 to 600 deliveries. Prematurity, fetal macrosomia, anencephaly, and cephalopelvic disproportion (CPD) are the major obstetric factors that predispose the fetus to face presentation. Although the mechanisms of labor in face presentation are different from those of simple vertex presentation, there is no consistent alteration in the duration of labor in the absence of underlying CPD. When disproportion does not exist and gross anomalies are not present, the prognosis for spontaneous vaginal delivery is excellent. The majority of perinatal losses reported in face presentation have resulted from traumatic operative vaginal deliveries, specifically version and extraction and midforceps rotations. Recent experience at this institution with a limited series of face presentations demonstrates that, with careful intrapartum surveillance, delivery can be accomplished with no increase in risk to either mother or fetus.

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• Face and brow presentation in northern Jordan, over a decade of experience. Zayed F, Amarin Z, Obeidat B, Obeidat N, Alchalabi H, Lataifeh I. Zayed F, et al. Arch Gynecol Obstet. 2008 Nov;278(5):427-30. doi: 10.1007/s00404-008-0600-0. Epub 2008 Feb 19. Arch Gynecol Obstet. 2008. PMID: 18283473
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Malpresentations and malpositions.

Published on 09/03/2015 by admin

Filed under Obstetrics & Gynecology

Last modified 09/03/2015

This article have been viewed 9550 times

Introduction

Malpresentation.

Malposition

During pregnancy, abdominal palpation should aim to define the lie, presentation and position of the fetus. The lie refers to the long axis of the fetus in relation to the long axis of the uterus. Usually, the fetus is longitudinal, but occasionally it may be transverse or oblique. The presentation is that part of the fetus which is at the pelvic brim, in other words the part of the fetus presenting to the pelvic inlet. Normal presentation is the vertex of the fetal head and the word ‘malpresentation’ describes any non-vertex presentation. This may be of the face, brow, breech, or some other part of the body if the lie is oblique or transverse.

The position of the fetus refers to the way in which the presenting part is positioned in relation to the maternal pelvis. Strictly speaking this refers to any presenting part, but here it will be considered in relation to those fetuses presenting head first (cephalic). As we have seen, the head is usually occipitotransverse at the pelvic brim and rotates to occipitoanterior at the pelvic floor. ‘Malposition’ is when the head, coming vertex first, does not rotate to occipitoanterior, presenting instead as persistent occipitotransverse or occipitoposterior.

As described above, ‘malpresentation’ is a term used to describe any non-vertex presentation. Over 95% of fetuses are in cephalic presentation at term. Malpresentations include face presentation, brow presentation and breech presentation. When the fetus has a cephalic presentation, the presenting diameter is dependent on the degree of flexion or extension of the fetal head – deflexed and brow presentations offer a wide diameter to the pelvic inlet ( Table 45.1 and Fig. 45.1 ).

Presenting diameters of the fetal head

Fig. 45.1 The presenting diameter is dependent on the degree of flexion or extension of the fetal head.

As the fetal skull is made up of individual bony plates (the occipital, sphenoid, temporal and ethmoid bones), which are joined by cartilaginous sutures (the frontal, sagittal, lambdoid and coronal sutures), it has the potential to be ‘moulded’ during labour. This allows the head to fit the birth canal more closely (Fig. 45.2) . Moulding should be distinguished from caput succedaneum, which refers to oedema of the presenting part of the scalp. Both moulding and caput can occur in any cephalic presentation, but are more likely to occur in malpresentation. The presence or absence of moulding and caput should be documented during each vaginal examination in labour; excessive moulding and caput are suggestive of an obstructed labour due to cephalopelvic disproportion.

Fig. 45.2 ‘Moulding’ refers to the change in shape of the fetal skull during labour as it ‘moulds’ to the birth canal.

Caput refers to oedema of the presenting part of the scalp.

Face presentation

This occurs in about 1:500 births and occurs when the fetal head extends right back (hyperextended so that the occiput touches the fetal back) (Fig. 45.3 A) . It is associated with prematurity, tumours of the fetal neck, loops of cord around the fetal neck, fetal macrosomia and anencephaly. Face presentation is usually only recognized after the onset of labour and, if the face is swollen (Fig. 45.3 B) , it is easy to confuse this presentation with that of a breech. The position of the face is described with reference to the chin, using the prefix ‘mento’. The presenting diameter is submentobregmatic (9.5 cm) (Fig. 45.1) .

Fig. 45.3 Face presentation.

(A) The head enters the pelvic brim in the transverse position. (B) Most rotate to the mentoanterior position and deliver without problems. (C) Those that rotate to mentoposterior will obstruct. (D) Face presentation is often associated with oedema and bruising. This baby recovered without problems.

The face usually enters the pelvis with the chin in the transverse position (mentotransverse) and 90% rotate to mentoanterior so that the head is born with flexion (Fig. 45.3 C) . If mentoposterior, the extending head presents an increasingly wider diameter to the pelvis, leading to worsening relative cephalopelvic disproportion and impacted obstruction (Fig. 45.3 D) . A caesarean section is usually required.

Brow presentation

This occurs in only approximately 1:700 and 1:1500 births and is the least favourable for delivery (Fig. 45.4) . The presenting diameter is mentovertical, measuring 14 cm. The supraorbital ridges and the bridge of the nose will be palpable on vaginal examination. The head may flex to become a vertex presentation or extend to a face presentation in early labour. If the brow presentation persists, a caesarean section will be required.

Fig. 45.4 Brow presentation.

Breech presentation

Breech presentation describes a fetus presenting bottom first. The incidence is around 40% at 20 weeks, 25% at 32 weeks and only 3–4% at term. The chance of a breech presentation turning spontaneously after 38 weeks is < 4%. Breech presentation is associated with multiple pregnancy, bicornuate uterus, fibroids, placenta praevia, polyhydramnios and oligohydramnios. It may also rarely be associated with fetal anomaly, particularly neural tube defects, neuromuscular disorders and autosomal trisomies. At term, 65% of breech presentations are frank (extended) with the remainder being flexed or footling (Fig. 45.5) . Footling breech carries a 5–20% risk of cord prolapse ( p. 367 ).

Fig. 45.5 Breech presentation.

Those presenting by the breech may be (A) extended (or frank); (B) flexed; or (C) footling.

Mode of delivery

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face presentation

Learn about this topic in these articles:, complication of childbirth.

Face presentation and transverse (cross) presentation are rare.

When the child’s head becomes bent back (extended) so that it enters and passes through the pelvis face first, the condition is known as a face, or cephalic, presentation. The chin is then the leading pole and follows the same course that is…

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Presidential campaigning and presentations.

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Vector illustration of a businessman or politician speaking to a large crowd of people

Now that the full slates of candidates for the November presidential election are set, it is time to examine the parallels between political campaigns and presentations—both being highly mission critical forms of communication in which the end goal is persuasion. As the candidates fan out across the country, the airwaves, the cable channels, the internet, and reams of print, they will try to convince voters that they are best qualified to run the country. If history is any indicator, the candidates will do that by spending most of their time and space citing their own credentials. And this year, to date, the candidates have also spent a great deal of their time and space making ad hominem attacks against their opponents.

This is the equivalent of presenters spending most of their time and space extolling the virtues of their products, services, or technology, and bashing the competition.

For both presenters and politicians this approach is misguided on two counts: focus and contentiousness.

Karen Hughes has a solution for focus. Although Hughes is now the global vice chair of the public relations firm Burson-Marsteller, her main claim to fame was the primary communications consultant for President George W. Bush’s two successful campaigns for the presidency. In her autobiography, Ten Minutes from Normal , she tells of the time she was strolling along a beach and saw a small plane towing a banner that read, “MARILYN IVE POURED MY [heart emoticon] OUT NOTHING LEFT LUV WES.”

It made her think:

The banner is clearly some sort of appeal to Marilyn, but the words are about Wes—what he has done, how he feels. He should have made this message about her.

Hughes’ advice to Wes is spot on. Clearly, Wes had committed the common relationship felony of being “All about you, Babe!”

In both politics and presentations this means making it all about them . Rather than spending precious time and space time on what is known in football as “flooding the zone” with features and credentials respectively, candidates and presenters must instead provide benefits for the voters and the audience.

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While political campaigns are of the moment and presenting to win in business is the constant focus of this blog, all other forms of communication—conversations, meetings, sales, correspondence, negotiations, social chatter—must always focus on the opposite party and do so without contention.

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