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doi:10.1111/jog.12369

J. Obstet. Gynaecol. Res. Vol. 40, No. 6: 15731577, June 2014

Face presentation at term: A forgotten issue

Omer L. Tapisiz1, Hakan Aytan1, Sadiman Kiykac Altinbas2, Feyza Arman1,
Gorkem Tuncay1, Mustafa Besli1, Leyla Mollamahmutoglu1 and Nuri Dansman1
1

Department of Obstetrics and Gynecology, Ministry of Health, Dr. Zekai Tahir Burak Womens Health Education and
Research Hospital, and 2Department of Obstetrics and Gynecology, Ministry of Health, Etlik Zubeyde Hanim Womens Health
Teaching and Research Hospital, Ankara, Turkey

Abstract
Aim: To determine factors associated with face presentation of term fetuses delivered.
Methods: Of 34 480 consecutive, term deliveries of uncomplicated pregnancies within a 3-year period, all live,
singleton term fetuses with cephalic presentation in which no lethal anomalies occurred that were diagnosed
with a face presentation were studied. Factors that may have contributed to the etiology of the presentation
including age, parity and fetal size were evaluated. Ultrasonographic evaluation was recorded.
Results: Fifty cases were diagnosed with an incidence of 0.14%. Parity was not associated with face presentation. Birthweight of 4000 g or more indicated an increased risk of approximately 2.9-fold, whereas fetuses
weighing 30003499 g were found to have a relatively decreased risk of face presentation when compared with
the general obstetrics group (P = 0.015 and 0.001, risk ratio = 2.948 and 0.450, respectively). With physical
examination, only 70% were diagnosed correctly.
Conclusion: Face presentation is a rare event and birthweight more than 4000 g was found to be associated
with face presentation. Parity is not an associated factor.
Key words: face presentation, birthweight, parity, term pregnancy.

Introduction
Face presentation is a rare event characterized by a
longitudinal lie and full extension of the fetal head on
the neck with the occiput against the upper back. The
reported incidence ranges 0.140.54%.14 Diagnosis is
suspected by abdominal palpation but may not be
detected on abdominal palpation only, especially if the
mentum is anterior. While the limbs may be palpated
on the side opposite to the occiput and the fetal heart is
heard on the same side as the limbs are in a mentum
anterior position, the fetal heart is difficult to hear as
the fetal chest is in contact with the maternal spine in a
mentum posterior position. On digital examination,

orbital ridge, orbits, saddle of the nose, mouth and chin

can be palpated. However, face presentation is more
often discovered by digital examination and confirmed
by radiography or ultrasound with a view of hyperextended fetal neck. Causes of face presentation are
numerous, generally stemming from any factor that
favors extension or prevents head flexion. Congenital
malformations, especially anencephaly,5 high parity
leading to pendulous abdomen,6 very large fetus,
contracted pelvis or cephalopelvic disproportion,2,4,7
marked enlargement of the neck or coils of cord about
the neck in exceptional instances are noted factors.
There are only a few recent reports on this clinical
entity that may result in increased fetal morbidity and

Received: May 10 2013.

Accepted: December 2 2013.
Reprint request to: Dr Omer L. Tapisiz, 1425. Cadde, Hayat Sebla Evleri, C Blok no. 74, Cukurambar, Ankara, Turkey.
Email: omertapisiz@yahoo.com.tr
Declaration: All authors have contributed significantly to this study and all authors are in agreement with the content of the
manuscript.

2014 The Authors

Journal of Obstetrics and Gynaecology Research 2014 Japan Society of Obstetrics and Gynecology

1573

O. L. Tapisiz et al.

mortality if not diagnosed early and managed properly.

The aim of this study was to determine the factors
associated with face presentation of term fetuses.

Methods
A retrospective study including 34 480 consecutive
term deliveries of uncomplicated pregnancies in the
delivery unit of a research and education hospital
within a 3-year period was conducted. All live, singleton term fetuses with cephalic presentation in which no
lethal anomalies occurred and were diagnosed with a
face presentation were included in the study. Multiple
pregnancies were excluded from the analysis. The perinatal data were collected from patient files and either a
resident or an expert made the diagnosis. An experienced obstetrician confirmed all diagnoses. Various
factors that might have contributed to the etiology of
the presentation, including age, parity and fetal size,
were evaluated. Inlet contraction was defined as a
diagonal conjugate of less than 11.5 cm. Ultrasonographic evaluation of the fetuses was recorded.
The ethical committee approved this study protocol.
Data were stored and analyzed using SPSS version
10.0 for Windows. Measurements of variables were
expressed as means standard deviation for descriptive statistics and the level of statistical significance was
set at 0.05. Parity and birthweights were compared
between the face presentation group and all deliveries
using Students t-test, 2-test and Fishers exact test.

Results
During the study period, 50 cases of face presentation
at term were diagnosed among 34 480 consecutive
deliveries with an incidence of 0.14%. Twenty-four
cases (48%) were primigravida, whereas 6% (n = 3)
were grand multiparous (>4 deliveries). Parity was not
found to be significantly associated with face presentation. Table 1 shows the distribution of parity in the
study group and all deliveries. The age of the patients
ranged 1640 years with a mean of 27.24 6.09 years.
Most of the patients received prenatal care and had at
least one antenatal visit during their pregnancy. None
of the patients had a history of cesarean delivery
because of our elective cesarean section policy. None of
the patients were manually rotated during delivery. All
infants were delivered by cesarean section.
The mean gestational age was 39.1 1.6 weeks. The
mean birthweight was 3356.8 562 g, ranging 2100
4340 g. The distribution of birthweights in the face presenting group and all deliveries is depicted in Table 2.
Birthweight was found to be associated with face presentation. Birthweight of 4000 g or more had an
increased risk of approximately 2.9-fold, whereas
fetuses weighing 30003499 g were found to have a
relatively decreased risk for face presentation when
compared with the general obstetrics group (P = 0.015
and 0.001, risk ratio = 2.948 and 0.450, 95% confidence
interval [CI] = 1.3286.543 and 0.2390.847, respectively) (Table 2).

Table 1 Comparison of parity in face presentation and whole obstetric population at the time of study

Primipara
Multiparous
Grand multiparous

Face
presenting
group

No. of
patients
(%)

All
deliveries

No. of
patients
(%)

RR

95% CI

24
23
3

48
46
6

14 687
17 492
2 301

42.6
50.7
6.7

0.817
0.503
0.570

1.068
0.827
0.899

0.6131.860
0.4751.440
0.3002.695

CI, confidence interval; RR, risk ratio.

Table 2 Comparison of birthweights in face presentation and whole obstetric population

Birthweight
(g)

Face
presenting
group

No. of
patients
(%)

All
deliveries

No. of
patients
(%)

RR

95% CI

20002499
25002999
30003499
35003999
4000

2
12
13
16
7

4
24
26
32
14

1 292
8 044
15 114
8 253
1 777

3.7
23.4
43.8
23.9
5.2

0.563
0.910
0.011
0.181
0.015

1.070
1.038
0.450
1.495
2.948

0.2604.399
0.5301.986
0.2390.847
0.8262.708
1.3286.543

CI, confidence interval; RR, risk ratio.

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2014 The Authors

Journal of Obstetrics and Gynaecology Research 2014 Japan Society of Obstetrics and Gynecology

Face presentation of term fetuses

As all term pregnancies were included in the

study, there were no preterm deliveries and/or premature rupture of membrane cases. Four cases of gestational diabetes mellitus (DM) were determined
(8%), and there were no cases with pregestational
DM.
At the examination of fetal presentation and position
on admission, 26% of the cases were wrongly diagnosed as vertex, 2% as breech and 2% as brow presentations; 70% were diagnosed correctly. In one patient,
face presentation was determined only during the
second stage of labor. In six patients, the diagnosis was
made before onset of the active phase of labor. Twentyfour infants were in mentum posterior position, 12
mentum anterior and 14 mentum transverse. Eight
cases (16%) were both primigravida and had a diagonal
conjugate of less than 11.5 cm with a mean birthweight
of 3453.73 101 g. When compared with the other
42 cases without the inlet contraction, the mean
birthweight was 3338.33 601 g and there was no significant difference with respect to birthweight
(P = 0.410). However, when compared with other primigravida patients, there was a significant difference in
birthweights between these eight cases and the
remaining 16 cases (3453.73 101 vs 2833.12 388,
P = 0.001; 95% CI = 297.95943.29).
Diagnosis was based on vaginal examination. No
abdominal X-ray was performed for confirmation. All
patients had transabdominal ultrasound examination
for determination of the fetal presentation, gestational
age and estimated fetal weight. Face presentation was
suspected in 23 (46%) of the cases. Among these cases,
the view of hyperextension of the neck and deflexion
was observed in 11 cases (22%). In 27 cases (54%),
vertex presentation was reported. Face presentation
was determined as the labor progressed in all of these
cases by digital examination, whereas in 10 of 27
patients, a second confirmatory sonography was performed in the labor unit.
There was no perinatal mortality. Non-reassuring
fetal heart rate pattern was determined in 14 (28%)
cases. Among these cases, three infants with late
decelerations on tracing, in whom thick meconium in
amnion were determined, and had low 1-min Apgar
scores of 3, 5 and 6, respectively, needed neonatal intensive care unit support. There were no infants with a
1-min Apgar of less than 3. One infant in this series had
spina bifida that was determined before delivery
during ultrasonographic examination. He was a 2720-g
male infant with a 1- and 5-min Apgar score of 7 and 9,
respectively. There were no other perinatal morbidities.

Among 50 neonates, 46% (n = 23) of them were male

and 54% (n = 27) were female.

Discussion
In the current study, face presentation with an incidence of 0.14% was found. Parity was not found to be
associated with face presentation. Birthweight of
4000 g or more had an increased risk of approximately
2.9-fold, whereas fetuses weighing 30003499 g were
found to have a relatively decreased risk of face presentation when compared with the general obstetrics
group.
A number of predisposing factors have been
implicated by various authors in the etiology of face
presentation. Anencephaly, multiparity, fetal size and
prematurity are the causative factors most frequently
cited.
Anencephaly and prematurity are out of the scope of
this study as non-anomalous term infants were
enrolled.
Multiparity is another cited factor810 that was not
borne out in this study. Especially grand multiparity,
due to pendulous abdomen and increased maternal
age, was suggested to be associated with face presentation.11 Cruikshank and White8 found that the incidence of grand multiparity was twice as high in cases
of face presentation as in the general obstetric population. On the other hand, other reports, including this
one, have found no significant differences between the
two groups with regard to multiparity.5,7,12,13 In this
study, we demonstrated that with respect to face presentation, grand multiparity has a relative risk of 0.899
with a 95% CI of 0.32.695 meaning that grand multiparity is not associated with face presentation in term
infants without a lethal anomaly. This is similar to the
findings of Zayed et al.14
Fetal size was found to be of etiologic importance in
this study. Infants weighing more than 4000 g were
found to have an approximately 2.9-fold increased risk
of face presentation when compared with infants
weighing less than 4000 g (95 % CI, 1.3286.543).
Infants weighing 30003500 g had an approximately
0.45-fold decreased risk (95% CI, 0.2390.847). In previous reports suggesting fetal weight to be of etiologic
importance,7,8,15 mainly large fetuses (>4000 g) were of
concern when anomalous infants were excluded. Face
presentation among term-size fetuses is common when
there is some degree of pelvic inlet contraction. The
incidence of inlet contraction was found to be 1040%
in some studies.2,4,7 In this study, inlet contraction was

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Journal of Obstetrics and Gynaecology Research 2014 Japan Society of Obstetrics and Gynecology

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O. L. Tapisiz et al.

determined in 16% of the cases, all being primigravida

with a mean birthweight of 3453.73 101 g, which was
not significantly different. Prematurity was suggested
to be associated with face presentation by various
authors,7,9,16,17 but not all would agree.3,8,12 In our series,
while there were no cases with pregestational DM, four
cases of gestational DM were determined (8%) in the
face presenting group. Among these four patients,
three of them had babies weighing 4000 g or more; one
of them delivered a baby with a birthweight of 3890 g.
Early diagnosis is of utmost importance as perinatal
mortality may be higher with late diagnosis.2 Diagnosis
based on physical and vaginal examinations require
experience. Campbell reported that, in practice, fewer
than one in 20 infants with face presentation is diagnosed abdominally18 and in various studies it is stated
that in fact only half of these infants are found to have
a face presentation by any means prior to the second
stage of labor4,5,15 and half of the remaining cases are
undiagnosed until delivery.4,7 In our study, 70% of the
cases were diagnosed correctly by physical examination. Most commonly, the presenting part was misdiagnosed as vertex, followed by breech and brow, which
should be considered in differential diagnosis.19
Diagnosis must be confirmed by radiography or
ultrasound. In this study, ultrasonography was used as
confirmation and no X-ray was performed. The
ultrasonographic evaluations were performed either
during admission to the hospital or to the labor unit
based on indications from the physicians. If deflection
is included as a correct diagnosis, because further
extension of an intermediate deflection to a fully
extended position may occur as labor progresses due to
resistance exerted by the pelvic bony and soft tissues, it
may be difficult to demonstrate face or brow presentation directly on ultrasound imaging because of the
location of the fetal head in the birth canal inferior to
the maternal symphysis pubis resulting in suboptimal
resolution.20 Although the advantages of a transvaginal
scan with a better resolution of the presenting parts has
been emphasized, the risk of injury to the fetal orbits
and maternal discomfort was also noted. Additional to
these techniques, translabial ultrasound has been demonstrated as an advantageous technique with the documentation of landmarks and the management of the
second stage of labor.20,21 In our obstetrics practice,
diagnostic ultrasound is widely used in the labor unit
for the estimation of fetal weight, presentation and
gestational age.
Reported perinatal mortality, corrected for nonviable malformations and extreme prematurity, varies

1576

from 0.6%18 to 5%,7 and cesarean delivery has been

reported in up to 67.1% of cases of face presentation.3,22
Except for mentum posterior cases, safe vaginal delivery is suggested to be accomplished,23 and a trial of
labor with careful monitoring of fetal condition and
progress is not contraindicated unless macrosomia or
a small pelvis is identified. In the published work,
vaginal delivery rates differ from 56% to 84%
(mentum anterior cases).14,24 In this study, all infants
were term and were delivered by cesarean regardless
of the position of the fetal chin. There were no maternal or fetal perinatal mortalities and morbidities. There
was no laryngeal and/or tracheal edema resulting
from pressures of the birth. The physicians decided to
perform cesarean delivery as soon as they diagnosed
face presentation without waiting for progression. This
is probably because obstetricians harbor a fear that
they may be criticized in hindsight for failure to
perform an earlier cesarean delivery that might have
resulted in a better outcome. All over the world, the
cesarean delivery rate has become higher and cesarean delivery liberally used as part of a trend in
modern obstetrics, not only to achieve a safer delivery
and patient satisfaction, but also to achieve the protection of the surgeon him/herself. The result is a more
defensive approach to practice, including a lower
threshold for resorting to cesarean delivery.25 A limitation of our study is that it is retrospectively designed
and therefore only a collection of existing data about
the issue. All in all, we believe that in the absence of a
contracted pelvis, and with effective labor, successful
vaginal delivery may be performed as written in the
textbooks.26
In conclusion, face presentation has an incidence of
0.14% at term and infants weighing more than 4000 g
have an approximately 2.9-fold increased risk for this
malpresentation. Term infants of average size (3000
3500 g) have a decreased risk in face presentation, with
a relative risk of 0.45.

Disclosure
None declared.

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Journal of Obstetrics and Gynaecology Research 2014 Japan Society of Obstetrics and Gynecology

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