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Face and brow presentations in labor

INTRODUCTION At term, the fetal spine typically lies along the longitudinal axis
of the uterus, as this lie best accommodates the relatively long torso of the fetus within the
uterine cavity and positions the fetus for egress into the birth canal. The fetus usually maneuvers
to accommodate the breech and flexed legs in the broad uterine fundus and the head in the
narrower lower uterine segment. This seems to allow the best fit in the available intrauterine
space. During labor, presentation is further defined by the part of the fetus that leads into the
birth canal: vertex (occiput), face, brow, breech (frank, footling, complete), shoulder, or
compound (a limb and head or breech). Fetuses in transverse or oblique lie have no presenting
part descending into the birth canal.
Determining fetal presentation is a crucial step in the evaluation of the laboring gravida. The
fetal presentation is usually identified during the course of labor by internal examination through
the dilating cervix. The occiput is smooth and hard, while the face, brow, breech, and fetal
extremities tend to be soft and/or have a more irregular contour. Identification of
malpresentations through the undilated cervix or myometrium prior to labor is possible, but
challenging and less reliable because maternal tissues obscure the fetal landmarks denoting
presentation.
INCIDENCE OF MALPRESENTATION The most common fetal presentation in labor is
vertex, which occurs in 96 percent of fetuses at term; 91.4 percent of fetuses present in vertex
occiput anterior (OA) [ 1 ]. Fetuses that are not in vertex OA presentation are considered to have
a malpresentation. At term, the types and estimated incidences of malpresentations are [ 1-7 ]:

Breech (1/33 deliveries)

Cephalic malpresentations (1/18 deliveries)

Vertex occiput posterior (1/19 deliveries)

Face (1/600 to 1/800 deliveries)

Brow (1/500 to 1/4000 deliveries)

Compound (1/1500 deliveries)

Transverse lie (1/833 deliveries)

CONSEQUENCES OF MALPRESENTATION The most efficient way for the fetus to


negotiate the birth canal is in vertex presentation. With this presentation, the biparietal plane of
the fetal head enters the pelvic inlet (called engagement) during labor, although sometimes this
occurs antepartum [ 8 ]. As the head continues to descend beyond the pelvic inlet, pressure and
resistance from maternal soft tissues cause the fetal neck to flex so that the chin comes into

contact with the chest. Flexion allows the head to have room to descend the length of the birth
canal whether the head is occiput anterior or occiput posterior. The remaining cardinal
movements of labor follow: internal rotation and extension of the neck, external rotation
(restitution), and finally complete expulsion of the fetus.
By the comparison, the neck of the fetus in face or brow presentation is deflexed (extended
backwards). The wider head diameters that present when the neck is deflexed inhibit head
engagement and subsequent fetal descent.
FACE PRESENTATION In face presentation the fetal neck is sharply deflexed, allowing the
occiput to touch the back and the face (from forehead to chin) to present in the birth canal (
figure 2 ).
Etiology and risk factors The cause of face presentation is unknown. It is presumed to occur
because of factors that favor extension or prevent flexion of the fetal neck. A common risk factor
is an anomalous fetus, particularly one with anencephaly, massive hydrocephalus, or an anterior
neck mass [ 7 ]. Multiple nuchal cord loops may also prevent flexion of the head [ 2 ], although
the majority of fetuses with multiple loops of nuchal cord do not have a malpresentation [ 5 ].
Other factors that have been associated with face presentation include cephalopelvic
disproportion, prematurity/low birth weight, macrosomia, contracted maternal pelvis,
platypelloid pelvis ( figure 3 ), polyhydramnios, previous cesarean delivery, black race, and
multiparity [ 9-12 ].
Extreme laxity of the anterior abdominal wall may predispose multiparous women to fetal
malpresentation. Lack of muscle tone may permit the uterine fundus and fetal trunk to swing
anteriorly, which may extend the cervical spine, leading to a face or brow presentation [ 11 ].
Others have suggested that the higher rate of face (and brow) presentation in multiparous women
may be due, in part, to later engagement of the vertex in these women, often after the onset of
labor [ 10 ]. The association with polyhydramnios may be a secondary effect of impaired
swallowing due to obstruction of the fetal trachea and esophagus from a hyperextended fetal
neck [ 5 ]. Polyhydramnios also occurs with fetal anomalies associated with face presentation,
particularly anencephaly [ 10 ]. The increased frequency of prior cesarean delivery in
pregnancies with face and brow presentation may be explained by a contracted maternal pelvis,
which predisposes to both dystocia and malpresentation [ 10 ]. Black race has also been
associated with face presentation, possibly due to differences in pelvic shape and a higher rate of
prematurity in black women [ 11 ]. Prematurity has been linked to face presentation, possibly
because a very small fetus can descend with the neck partially extended; however, the
association between prematurity and face presentation is weak [ 11,12 ].
Diagnosis The diagnosis of face presentation is usually made late in the first stage or in the
second stage of labor [ 5 ]. On digital examination, landmarks indicating a face presentation are
the ability to palpate the orbital ridge and orbits, saddle of the nose, mouth, and chin ( figure 4 ).
Sonography of a face presentation will show a hyperextended fetal neck. Although imaging
studies can be performed to confirm the diagnosis if it is uncertain or internal examination

cannot be done, imaging is not mandatory and results do not have prognostic value for predicting
the outcome of labor.
Differential diagnosis A face may be mistaken for a breech on blind digital examination since
the latter is more commonly encountered (and therefore expected) and both are comprised of soft
tissues with an orifice. Careful palpation will reveal the bony facial structures and lead to the
correct diagnosis.
Course and management of labor At the time of diagnosis, nearly 60 percent of face
presentations will be in the mentum anterior position, 26 percent will be mentum posterior, and
15 percent will be mentum transverse [ 9 ]. Thirty to 50 percent of fetuses in mentum posterior
and mentum transverse positions will spontaneously convert to the mentum anterior position
during the course of labor [ 9 ]. This is important since at term only mentum anterior face
presentations are likely to deliver vaginally (see 'Mentum anterior' below and 'Mentum posterior'
below).
The management of face presentation requires close observation of the progress of labor because
cephalopelvic disproportion is more likely than with vertex presentation. As noted above, during
labor in the vertex presentation, flexion of the neck normally brings the chin to the chest,
resulting in the relatively small suboccipitobregmatic diameter (average length 11.9 cm [ 13 ]) as
the widest diameter negotiating the maternal pelvis. This diameter is able to traverse the
obstetrical conjugate.
By comparison, the widest diameter of the fetal head negotiating the pelvis in face presentation is
the trachelo-bregmatic or trachelo-parietal diameter (also called trachelo- or submento-parietal;
average length 12.6 cm), which is 0.7 cm greater than the suboccipito-bregmatic diameter
(average length 11.9 cm) of a normally flexed vertex presentation ( figure 5 ) [ 13 ]. Despite the
increased diameter, over 75 percent of mentum anterior fetuses are delivered vaginally, whereas
persistent mentum posterior and transverse fetuses require cesarean birth (see 'Mentum anterior'
below and 'Mentum posterior' below) [ 2,3,11,14,15 ].
Abnormalities of the fetal heart rate occur more frequently with face presentations [ 4,14,16 ]. In
one series, for example, severe variable and late decelerations developed in 29 and 24 percent of
labors, respectively [ 16 ]. Only 14 percent of patients had normal tracings. Moreover, 13 percent
of the infants had a low five-minute Apgar score. For this reason, these fetuses should be
continuously monitored during labor, ideally with an external device. An internal device may
cause facial or ophthalmic injuries if improperly placed [ 17,18 ]. If internal monitoring is
needed, the electrode should be cautiously applied over a bony structure such as the forehead,
mandible, or zygomatic bones to minimize the risk of trauma [ 16 ].
Mentum anterior Once engagement has occurred in a mentum anterior face presentation, the
fetal neck extends even further backward such that the occiput touches the back. Internal rotation
occurs between the level of the ischial spines and ischial tuberosities, making the chin the actual
presenting part of the face [ 5 ]. As the face descends onto the perineum, the fetal chin passes
under the maternal symphysis pubis, slight flexion of the neck occurs, and delivery is possible
via maternal expulsive forces.

The parturient may begin pushing at full dilatation. Oxytocin augmentation may be given if
indicated and the fetal heart rate pattern is reassuring [ 14 ]. Outlet forceps should only be used
by experienced practitioners. Since engagement does not occur until the face is at +2 station,
forceps should only be applied to the face that is bulging the perineum [ 5 ]. Attempts at version,
extraction, or midforceps delivery should be avoided, as they are associated with unnecessary
maternal trauma and neonatal injury [ 19 ].
Mentum posterior In the mentum posterior position, the neck, head, and shoulders must enter
the pelvis simultaneously; however, the pelvis is usually not large enough to accommodate the
fetal trunk in this position. In addition, the fetal neck must extend the length of the maternal
sacrum (average 12 cm) in order to reach the perineum, but the fetal neck is too short to
accomplish this task. Lastly, an open fetal mouth may act as a fulcrum against the sacrum
preventing further descent. Therefore, the mentum posterior face presentation will not deliver
vaginally unless spontaneous rotation occurs or the fetus is very small (eg, very preterm) ( figure
6 ). In one series, 11 of 12 fetuses in the mentum transverse position and 2 of 10 patients with
mentum posterior delivered vaginally after spontaneous rotation to mentum anterior [ 14 ].
In the past, manual conversion of the mentum posterior face to a vertex or mentum anterior
position was attempted using internal and external manipulation [ 20,21 ]. Although some
operators have been successful with no significant neonatal or maternal complications, others
have described cases of maternal death from uterine rupture, neonatal asphyxia secondary to cord
prolapse, and devastating neonatal neurologic sequelae from cervical spine trauma [ 19 ]. Given
the safety and ready availability of cesarean delivery, there is little justification currently for use
of internal version. This procedure should be reserved for occasions when an operative delivery
is unable to be accomplished due to lack of surgical facilities and inability to arrange maternal
transport, or absolute maternal refusal to allow a cesarean birth [ 21 ].
Neonatal outcome Prior to 1955, increased rates of intrapartum fetal death and perinatal
mortality (approximately 10 percent) were reported with face presentation [ 5 ]. Perinatal
mortality decreased to 2 to 3 percent by 1980, likely due to the increased use of cesarean
delivery, as well as other advances in obstetrical and neonatal care [ 5 ].
Neonates who were in face presentation often have significant facial edema and skull molding [
8 ]. This usually resolves within the first 24 to 48 hours of life. Difficulty in ventilation during
resuscitation has been reported and attributed to tracheal and laryngeal trauma and edema.
Therefore, equipment and personnel to perform endotracheal intubation should be readily
available at the time of delivery [ 16 ].
Facial trauma and spinal cord injury have also been described in case reports, and often involve
version, extraction and midforceps rotations [ 2,16,18,22 ]. Appropriate management of face
presentation, as described above, typically does not result in increased serious maternal or
neonatal morbidity [ 2 ].
BROW PRESENTATION The fetus in the brow presentation occupies a longitudinal axis
with the fetal neck extended, but not to the degree in face presentation ( figure 2 ). The area
presenting in the birth canal typically extends from the anterior fontanelle to the brow (orbital

ridge), but does not include the mouth and chin. The brow presentation is often a transitional
state: further neck extension leads to a face presentation or neck flexion results in vertex
presentation in 50 percent of cases. Persistent brow presentation is not compatible with vaginal
birth unless the fetus is very small.
Etiology and risk factors The etiology of brow presentation is unclear. A contracted pelvis is
the most consistent risk factor [ 5 ]. It is possible that fetuses delivered from the occiput posterior
position were brow presentations at the onset of labor [ 23 ].
Diagnosis The diagnosis of brow presentation is usually made late in the second stage of
labor [ 5 ]. On digital examination, landmarks indicating brow presentation are the ability to
palpate the forehead, saddle of the nose, and orbits. Face presentation is excluded because the
mouth and chin are not palpable. The brow may be anterior or posterior ( figure 7A-B ).
If the diagnosis is uncertain after physical examination, ultrasound may be helpful. In a case
report of suspected brow presentation, ultrasound showed that the fetal orbits were just below the
symphysis pubis, which differs from a typical occipito-posterior presentation [ 24 ].
Course and labor management The head in brow presentation engages transversely at the
pelvic brim. As the fetus descends into the birth canal, internal rotation to brow anterior occurs
and causes the occiput to become wedged in the sacral hollow. Downward pressure from uterine
contractions and maternal pushing force the mentum to extend further anteriorly, resulting in a
mentum anterior face presentation [ 5 ]. Alternatively, internal rotation may rotate the face to
under the symphysis pubis and the neck may flex to the vertex occiput posterior position.
Conversion to occiput anterior is rare.
If internal rotation does not occur, the mento-parietal diameter presents at the pelvic inlet and
must pass through it for engagement to occur. The mento-parietal (or mento-bregmatic) diameter
is the largest diameter of the fetal head (13.4 cm), 0.8 cm wider than the trachelo-parietal
diameter (12.6 cm) of the face presentation and nearly 1.5 cm wider than the suboccipitobregmatic diameter (11.9 cm) of the vertex presentation [ 13 ]. Therefore, the possibility of
dysfunctional, prolonged labor and cephalopelvic disproportion is high if this presentation
persists [ 5,13 ]. Successful vaginal delivery of a persistent brow presentation is only possible in
an extremely small or macerated infant, or with an unusually large maternal pelvis.
Women with a clinically adequate or proven pelvis can be allowed to labor since a large
proportion will deliver vaginally. In one review, when brow presentation was diagnosed early in
labor, 67 to 75 percent of fetuses spontaneously converted and delivered vaginally; when
diagnosed late in labor, 50 percent spontaneously converted (30 percent converted to a face
presentation and 20 percent converted to vertex presentation) and delivered vaginally [ 2,5 ].
Labor should be monitored closely, with cesarean delivery if progress is protracted or arrested.
Vaginal delivery is less likely when the pelvis is narrow or contracted, so cesarean delivery early
in labor is a reasonable option for these women.
Patients in spontaneous labor are followed with continuous fetal heart rate monitoring and
frequent assessment of progress. The diagnosis of persistent brow presentation and protracted or

arrested labor necessitates an abdominal delivery; oxytocin augmentation is not recommended


given the association between brow presentation and cephalopelvic disproportion [ 5,14,20 ].
Version is not recommended, as the risk of perinatal mortality or uterine rupture is high [ 5 ].
Neonatal outcome Recognition and appropriate management of brow presentation, as
described above, typically do not result in increased serious maternal or neonatal morbidity.
SUMMARY AND RECOMMENDATIONS

The fetus in face or brow presentation has a deflexed (extended backward) neck, which
inhibits head engagement and subsequent fetal descent. (See 'Consequences of
malpresentation' above.)

Face and brow presentations are associated with multiparity, cephalopelvic disproportion,
prematurity, polyhydramnios, and fetal anomalies (eg, anencephaly, anterior neck mass).
(See 'Etiology and risk factors' above and 'Etiology and risk factors' above.)

In the face presentation with the mentum anterior or transverse, we suggest that labor be
allowed to progress. Oxytocin augmentation may be used in the setting of a normal fetus
with abnormally slow progress, as long as the fetal heart rate pattern remains reassuring.
(See 'Mentum anterior' above.)

The face presentation in persistent mentum posterior will not deliver vaginally; therefore,
abdominal delivery is indicated. (See 'Mentum posterior' above.)

There is an increased risk for fetal trauma with face presentations. Maternal and perinatal
mortality and morbidity associated with these abnormal presentations are probably not
increased if there is liberal use of cesarean delivery. Internal manipulation can be
traumatic and should be avoided. (See 'Neonatal outcome' above.)

The brow presentation is often a transitional state. Fifty percent of brow presentations
will spontaneously convert to a face or vertex presentation. Therefore, we suggest that
spontaneous labor be allowed to progress, with close monitoring and delivery by cesarean
when an arrest of progress is diagnosed. Persistent brow presentation is not compatible
with vaginal birth unless the fetus is very small. (See 'Course and labor management'
above.)

We suggest continuous intrapartum fetal heart rate monitoring using an external


monitoring device for malpresenting fetuses, as there is an increased risk of
nonreassuring patterns with malpresentations. (See 'Course and management of labor'
above.)

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